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NURSING THE INSANE 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON ■ CHICAGO 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



\ 



NURSING THE INSANE 



BY 



CLARA BARRUS, M.D. 

ft 
WOMAN ASSISTANT PHYSICIAN IN THE MIDDLETOWN STATE 
HOMEOPATHIC HOSPITAL, MIDDLETOWN, N.Y. 



Nefo fg0tft 

THE MACMILLAN COMPANY 

1908 
All rights reserved 



T?C440 



LIBRARY of CONGRESS. 


Two Copies 


rieceiv.v 


APR 20 


1908 


Joyyntrni 


entry 


olasS j 


"to 2 

XXc. (i'j. 


COHY 3. 



COPYRIGHT, 1908, 

By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published April, 1908. 



Norfooob 3Bres* 

J. 8. Cushing Co. — Berwick & Smith Co. 

Norwood, Mass., U.S.A. 



THE NURSES 

OF THE MIDDLETOWN STATE HOMEOPATHIC HOSPITAL 

IN GRATEFUL RECOGNITION OF THEIR FIDELITY 

IN THE CARE OF MENTAL INVALIDS 



PREFACE 

Within the memory of the passing generation our institu- 
tions for the insane have undergone remarkable changes in 
aims and character. From being merely places of detention 
and custody, they have evolved into modern hospitals which 
aim to provide comfortable, pleasant, and hygienic surround- 
ings for the patients, scientific treatment directed to the cure 
of the curable, and judicious and humane care for all. 

A large number of the population of every State hospital is 
composed of chronic and presumably incurable cases, but many 
are susceptible of marked mental improvement, and some of 
recovery. 

These patients make up a large community of peculiar and 
trying persons. To deal with them wisely and kindly requires 
exceptional qualities of mind and character. The training of 
nurses and attendants for these patients must cover a much 
wider field than is comprised in the course of the ordinary 
trained nurse. The nurse for the insane must be prepared to 
care for the ordinary medical and surgical diseases of her 
patients, in addition to their mental ailments; for insanity 
does not exempt them from the other ills that flesh is heir to. 
She must safeguard them from injuring themselves or others, 
must possess many of the qualities that make a good teacher, 
since a part of her duty is to help correct faults in early train- 
ing and development, and to encourage and train to correct 
and useful habits and proper behavior ; she has also to employ 
and entertain her patients, under the direction of the medical 
officers ; and to her is intrusted that almost constant association 
and companionship which, if sympathetic and judicious, is one 
of the most potent means of restoring her charges to mental 
health. 

To this end training schools are now established in all the 
State hospitals, where students receive special experience and 
instruction in the care of mental invalids, in addition to the 

vii 



viii PREFACE 

training ordinarily afforded in general hospitals. This in- 
struction is furnished by text-books, lectures, demonstrations 
in the operating room, and special clinics at the bedside and 
on the wards. 

This book, which started as a collection of familiar talks to 
nurses in charge of mental invalids, is the outgrowth of fif- 
teen years' experience in a large hospital for the insane. It 
does not pretend to cover the entire field of nursing, although 
many points in general nursing are necessarily included in it. 
Its aim is to furnish special instruction and suggestions to 
students engaged in caring for the insane, to help new 
workers to a right beginning, and to aid the more experienced 
ones to greater efficiency. 

Since my work has been almost entirely among women 
patients and students, it has seemed natural to address myself 
to women nurses, although many of the talks themselves were 
originally given to both sexes, and, in the main, are as appli- 
cable to men as to women nurses. 

I am aware that there is some repetition of ideas in the book. 
Written at different times and for different occasions — for 
probationers, junior, senior, and graduate nurses — it is perhaps 
inevitable that the work as a whole shows emphasis and reitera- 
tion along certain lines. But the things emphasized, the topics 
that reappear in the various talks, are things, I believe, of vital 
importance; and the principles I have tried to set forth seem 
to me so much in need of emphasis that I trust the various 
ways of presenting them will prove sufficiently helpful to 
excuse whatever repetition may be noted. 

The medical works and books on nursing which I have 
consulted in the preparation of this volume are too numerous 
to admit of special acknowledgment ; nevertheless, their help is 
gratefully appreciated. I am also much indebted to several 
of my confreres for valuable aid in the critical reading of the 
manuscript. 

If this book fulfills its aim, I shall feel it a privilege to have 
been in any way helpful to that noble body of men and women 
engaged in the humane service of ministry to minds diseased. 

CLARA BARRUS 



CONTENTS 



CHAPTEB *AGB 

I Outline of Nurses* Work in the New York State 

Hospitals 1 

II Introductory Talk to Nurses of the Insane . . 6 

m Rules to observe when on Duty 17 

IV The Reception of Patients 34 

V Ward Management and Duties of Charge Nurse . 49 

VI Hygiene of the Wards and of Hospital Departments 60 

VII The Care of Bed Patients 73 

VIII Bathing and Hydrotherapy 89 

IX The Preparation and Serving of Food .... 113 

X Practical Points in Nursing the Insane . . . 120 

XI The Observation of Symptoms 130 

XII Accidents and Emergencies 142 

XIII Care of Special Medical Cases 168 

XIV Some Points in Surgical Nursing of The Insane . 183 
XV Care of Gynecological and Obstetrical Cases : Puer- 
peral Insanity 198 

XVI Occupation and Amusement of Patients . . . 209 
XVn Sleep and the Conditions which Favor it: Duties 

of the Night Nurse 223 

XVHI A Talk on Psychology . . . ... .236 

XIX The Power of Habit 252 

XX Aids to Psychic Treatment 256 

XXI Applied Psychology 263 

XXII Mental Hygiene 273 

XXIII Normal and Abnormal Mentality 282 

XXIV Manifestations and Accompaniments of Insanity . 293 
XXV Forms of Mental Disease 309 

ix 



x CONTENTS 

CHAPTER PAGB 

XXVI Forms of Mental Disease (Continued) .... 328 

XXVII Nursing in the Various Forms of Mental Disease . 349 
XXVIII Nursing the Insane in Private Households and 

Sanitaria 380 

XXIX Miscellany : 

Commitment and Conveyance of Patients to State Hos- 
pitals 390 

Report of Journey 393 

Approach of Death, Religious Offices, Signs of Death, 

Care of the Dead 397 

Preparation for Autopsies 399 

Clothing and Belongings of Patients after Death . 400 

Index 401 



NURSING THE INSANE 



OTRSENTG THE INSAKE 

CHAPTER I 

OUTLINE OF NURSES 7 WORK IN THE NEW YORK STATE HOSPITALS 

There are thirteen State hospitals for the care of the insane 
in New York State, besides two for criminal insane, and twenty- 
three licensed sanitaria. In these institutions are treated more 
than twenty-eight thousand mental invalids. This number does 
not include the voluntary patients in unlicensed sanitaria, nor 
the patients being cared for in private households. 

With, then, this large number of mentally afflicted to be 
treated in New York State alone, it would seem desirable that 
thorough courses of instruction and training should be afforded 
the young men and women undertaking this humane but ardu- 
ous work. Such instruction the State hospital training schools 
aim to furnish. 

The State hospitals are under the control of the State Com- 
mission in Lunacy (a body composed of three commissioners, 
aided by a secretary, a medical inspector, an auditor, and a 
treasurer), whose official headquarters are in Albany, New 
York. 

Applicants who wish to enter the State hospital service may 
address communications to the Commission, or to the super- 
intendents of any of the hospitals named below : — 

New York State Hospitals Address 

Utica State Hospital, Utica, N.Y. 

Willard State Hospital, Willard, N.Y. 

Hudson River State Hospital, Poughkeepsie, N.Y. 
Middletown State Homeopathic Hospital, Middletown, N.Y. 

Buffalo State Hospital, Buffalo, N.Y. 

Binghamton State Hospital, Binghamton, N.Y. 



2 NURSING THE INSANE [Chap. I 

New York State Hospitals Address 

St. Lawrence State Hospital, Ogdensburg, N.Y. 

Rochester State Hospital, Rochester, N.Y. 

Kings Park State Hospital, Kings Park, L.I. 

Long Island State Hospital, Brooklyn, N.Y. 

Manhattan State Hospital, Ward's Island, N.Y. 

Central Islip State Hospital, Central Islip, N.Y. 
Gowanda State Homeopathic Hospital, Gowanda, N.Y. 

The requirements for entering the service of these hospitals 
are as follows : men and women of suitable age, preferably from 
twenty-one to thirty-five, of good character and in sound health, 
who have passed a non-competitive Civil Service examination at 
the hospital they wish to enter. 

Application blanks may be procured at any of the State 
hospitals, and at least two satisfactory letters of recommenda- 
tion must be submitted by the applicant, who needs, of course, 
to possess a common school education in order to pass the 
preliminary examination. 

On entering the service, the probationer, who is called an 
attendant, may wear ordinary clothing for one month, after 
which time, if his or her services prove satisfactory, the appoint- 
ment is usually confirmed, and the prescribed uniform must then 
be procured and worn at all times when on duty. 

Board, lodging, and laundry are furnished in addition to the 
wages, which will be mentioned later. In some cases, by special 
permission of the superintendent, and approval of the Com- 
mission, employees are allowed to board and lodge away from 
the hospital, and then a uniform rate of $12 a month is added 
to the monthly wages. Such employees are not entitled to 
the use of the laundry. 

Employees who are off duty as a result of illness not received 
in the fine of duty are not entitled to compensation for time lost. 

Attendants and nurses may be dismissed for disregarding 
rules or for unsatisfactory services. They are expected to pre- 
sent written resignations one month in advance, if intending to 
leave the service. 

The Training School for Nurses aims to offer instruction in 



Chap. I] NURSES* WORK IN NEW YORK HOSPITALS 3 

the general care of the sick and special instruction in the care 
of mental and nervous patients. Attendants showing fitness 
for the work are earnestly urged to enter the Training School, 
which holds its entrance examinations in June and early in 
September in all the State hospitals. A two-year course of 
lectures and recitations in anatomy and physiology and in 
general and special nursing, supplemented by practical ward 
and infirmary work, and hygienic housekeeping, comprises the 
training. Lectures and recitations last from October 1 till 
May 1, while the practical work continues throughout the 
year. Oral and written reviews are held from time to time 
during the year, and a written examination is held at the 
year's close. At the end of the two-year course the successful 
candidates are graduated and appointed as nurses, receiving 
a State diploma, and an increase of pay if they remain in 
the service. Postgraduate instruction is also provided in many 
of the hospitals, in which graduate nurses are helped to more 
advanced studies than are arranged for in the regular course, 
and where matters concerning which they have grown rusty or 
indifferent are brought to their notice. 

Applications are frequently made to the State hospitals for 
nurses trained in the care of the insane, and these hospitals 
occasionally supply the demand from their list of graduates who 
are engaged in private nursing. 

Nurses and attendants are entitled to an annual vacation of 
fourteen days; to each fourteenth day after the morning's work 
is performed, or its equivalent; and to each third Sunday; with 
full pay during such absences. Night nurses and attendants are 
not entitled to the fourteenth day. Other absences are granted 
at the discretion of the superintendent. 

Nurses and attendants are graded as follows : — 
Monthly Wages : — 

Charge nurses: men receive $35.00 to $41.25; women, $28.75 
to $35.00. 

Nurses: men, $31.25 to $37.50; women, $25.00 to $31.25. 

Charge attendants: men, $31.25 to $37.50; women, $25.00 to 
$31.25. 



4 NURSING THE INSANE [Chap. I 

Attendants: men, $22.00 to $30.00; women, $16.00 to $22.50. 

Dining room attendants : women, $17.50 to $22.50. 

Special attendants: men, $37.50 to $43.75; women, $31.25 to 
$37.50. 

Increase of wages from minimum to maximum are at the rate 
of $1.00 a month for each six months of continuous service. 

Transfer of employees from one State hospital to another may- 
be arranged only by obtaining the written consent of the super- 
intendents of the two hospitals, and in such cases only may the 
service be regarded as continuous. Discharged employees from 
one State hospital cannot obtain employment in another without 
the written approval of the superintendent who discharges t>em. 

Our large institutions for the insane are managed a 
uniform system, and while there are individual differences in 
the various institutions, the rules and requirements, the aims 
and the advantages, are practically the same in all. The Com- 
mission in Lunacy is over the entire hospital service ; the super- 
intendents have charge of their respective institutions ; they are 
aided by assistant physicians, stewards, matrons, supervisors, 
nurses, attendants, and other employees. 

The patients, both public and private, acute and chronic, 
are cared for in the various buildings arranged for their care, 
in some cases in large structures accommodating a great many, 
in others in detached cottages, accommodating only a few. 
Most of the State institutions combine these two methods of 
housing their patients. 

The large buildings contain the administrative quarters, 
often various industrial departments, the culinary departments, 
etc. The buildings set apart for the use of patients are usu- 
ally divided into wards or halls, leading off from which are 
rooms arranged for one, two, or more patients. On each of 
these wards, or halls, as a rule, in addition to the rooms above- 
mentioned, are sitting rooms, dining and serving rooms, dormi- 
tories, bath and toilet rooms, linen rooms, and a hospital or 
infirmary department, where the physically sick, the feeble, 
and those needing bed treatment are cared for, these cases 
being under the continual supervision of nurses both day and 
night. 



Chap. I] NURSES' WORK IN NEW YORK HOSPITALS 5 

The nurse in charge of a hall, together with a sufficient number 
of assistant nurses or attendants, usually rooms on her partic- 
ular ward; the other nurses and attendants occupy rooms 
provided for them at the Nurses' Home, detached from the 
buildings occupied by patients. Meals for nurses are, as a rule, 
served in the dining rooms provided for patients, but at different 
times than when the patients are congregated there. 

The proportion of nurses and attendants to patients is about 
one to nine. In the hospital most familiar to the writer, where 
the number of patients at present is 1340, the number of men 
nurses and attendants is 77, of women, 81. The force is con- 
siderably reduced at night, when a much smaller number is 
sufficient to look after the same number of patients. 

For the most part, women nurses and attendants are employed 
on wards for women patients, and men on wards for men patients, 
but it has been found advantageous in many of the hospitals to 
employ, in addition to the men nurses and attendants, some 
women attendants for the men's wards also. In many instances, 
the women so employed are married, and work in company 
with their husbands on the same ward. 

The duties of nurses and attendants may briefly be stated as 
follows : To familiarize themselves with, and faithfully obey, the 
rules of the hospital in whose service they engage; to promote 
the welfare of their patients in respect to bodily, mental, and 
moral needs; to strive to be loyal to superiors, and considerate 
and helpful to associates; to refrain from mentioning patients' 
names, histories, or peculiarities to people outside the service, 
and from gossiping concerning patients, employees, or officers 
with any one, inside the service or out. 



CHAPTER II 

INTRODUCTORY TALK TO NURSES OF THE INSANE 

I would have no young man or woman lightly engage in 
nursing the insane. It is work that claims the best of one's 
powers. 

The ideal nurse is one whose bodily presence breathes health 
and cleanliness, one of quiet garb, of noiseless step, of soothing 
hand, of cheerful spirit, and of hopeful heart, and one of ready 
but judicious sympathy. We must not forget the " low and 
gentle voice " which, if it be " an excellent thing in woman," 
is especially so in a nurse. 

To these qualities must be added punctuality, truthfulness, 
patience, obedience, caution, courage; a spirit of untiring help- 
fulness, a vigilance that never sleeps, a sympathy that is inex 
haustible, and a tact that can cope successfully with the most 
trying and complex of situations. 

The nurse for mental and nervous invalids needs to be especially 
careful to conceal prejudices, to beware of showing favoritism, 
to conquer resentment and antipathies, to study the art of 
peacemaking, to learn when to speak and when to refrain from 
speaking, when to act and when not to act. She must learn 
humility and forbearance; in short, she must so cultivate the 
virtues that she becomes but little lower than the angels. And 
here I am reminded of what George Eliot says: — 

" To be anxious about a soul that is always snapping at you 
must be left to the saints of the earth/' and you are no saints, 
but just mortal men and women who have undertaken a work 
that makes continual demands upon your moral as well as your 
physical strength. I would not have you think I underesti- 
mate these demands. I would only try to help you cope with 
them as I believe you wish to do, worthily and well. 

6 



Chap. II] INTRODUCTORY TALK TO NURSES 7 

I wish in this talk to engage the attention not only of beginners 
in the work, but also that of all nurses and attendants for the 
insane, to the end that each asks herself whether she is doing 
her utmost to bring about recovery in recoverable patients, 
and to ameliorate as far as possible the condition of those who 
must spend the remainder of their lives in some institution for 
the insane. 

I wish at the outset for each of you to think for a minute 
what this means — to be always under lock and key, deprived 
of liberty, subjected to the necessary rules of a large institution, 
to the authority of the superintendent, and the other attending 
physicians, to the directions of the supervisor, and sometimes 
also to the tyranny of attendants, who too often exercise an 
unwarrantable dictation over patients whom they are expected 
to care for, to guide, to console, and to encourage, but never to 
dictate to nor command. 

The progressive nurse is always on the alert to learn how she 
can grow more and more efficient, and here I wish to caution 
the experienced nurse against thinking there is nothing else 
for her to learn, no newer and better methods to adopt, no truer 
application of the old methods. 

Those of us who have been in the work many years have to 
acknowledge that some patients get well in spite of, rather 
than because of, our efforts; and that others drift into chronicity 
because we are wanting in the energy and resourcefulness to 
rouse them to activity and to mental restoration. Have we 
not seen patients that have been regarded as hopeless, un- 
accountably take a favorable turn and surprise every one by 
getting well ? Surely such may be said to recover in spite of us; 
some subtle influences have been at work of which we are not 
aware. These experiences make us see the necessity of study- 
ing into and revising methods needing revision, and of discover- 
ing new methods waiting for discovery, perhaps so near at hand 
that we are looking right over them, though earnestly desiring 
to see them. 

We need to keep step with the advance being made in the 
study and treatment of nervous and mental disorders. Anti- 
quated ideas and methods must be cast aside for newer, more 



8 NURSING THE INSANE [Chap. II 

enlightened views and methods; routine must give place to 
individualization. The necessary red tape of an institution 
must be supplemented by variety and freshness. We must get 
out of ruts, look at our patients with a fresh eye, and bestir 
ourselves to try something different if old ways have proved 
ineffectual. 

In our large institutions, it is true, the majority is made up 
of chronic and supposedly incurable patients, and "to expect 
a cure when a cure is logically impossible, is illogical." This 
is a truth we have a right to console ourselves with when we 
see, in spite of the utmost care, that a patient has drifted into 
the condition of chronicity. But be sure that the patient has 
received your utmost care, your best efforts, your unfailing 
efforts, to stimulate and to restore. Even then, be careful 
how you regard a given case as incurable. Better err on the 
side of hoping against hope than to relax in any particular 
efforts toward bringing about a recovery. Keep alive your 
own optimism even in the face of discouragement. Optimism 
is infectious. 

One sometimes hears a nurse say: "It is so discouraging 
caring for these chronic cases. If we could only have some- 
thing worth working for ! " Let me again and again warn you 
against regarding a patient as incurable; but, even granted 
that a given case is hopeless, or, suppose your entire service 
is composed of seemingly hopeless cases, what then? In the 
first place, it is your duty to minister to a chronic patient's 
physical wants just as conscientiously as though she were the 
most promising of patients. The bodily functions should be 
regularly and closely watched, and any irregularities promptly 
reported to the physician. Do not take it upon yourself to 
decide as to their importance ; let the physician do that. Your 
duty is to observe and report. The patient's appetite, the 
sleep, the functions of urination and of defecation, the menstrual 
function, the condition of the skin, the habits, tendencies, false 
beliefs, conduct — all these, and many others not enumerated, 
should be intelligently and regularly scrutinized by you, and 
any departure from the normal promptly announced to the 
attending physician. 



Chap. II] INTRODUCTORY TALK TO NURSES 9 

Because a patient's reason is dethroned, is the need all the 
more urgent that her body receive the strictest care of the nurse, 
so that it may be rendered as wholesome, tidy, and unobjectionable 
in every sense and to every sense, as possible; not by spasmodic, 
spiritless efforts, but by continuous, tireless, persistent efforts. 

" She has been that way for years," " She never brushes her 
teeth," " She will put butter in her hair," " We can't keep her 
from destroying her clothes " — familiar sentences, are they 
not ? Do you ever think how often you confront the physicians 
with such replies when they urge you to try to bring about a 
more desirable state of affairs? 

Instead of offering such stock answers, how would it do if 
you said to yourself, " Because she has been that way for years," 
or " Because she has this troublesome propensity," or " Because 
she is so negligent, disgusting, or unruly," " I will set my wits 
to work to counteract these tendencies, to break up these habits. 
I will begin work on some different line than has been adopted. 
I will get her into some new ruts at least. I will no longer 
stand by and say, 'Because she is that way, she shall continue 
to be that way.'" Beware of the attitude that shows strict 
adherence to the Biblical injunction, "Let him that is filthy be 
filthy still," but rather by a word in season and out of season, 
by line upon line, here a little and there a good deal, by precept 
and example, seek to instill into your patients a desire for cor- 
rect behavior, for doing things "decently and in order," for 
"ways of pleasantness" and "paths of peace." 

Try new and radical means for breaking up old habits. What 
transformations may result ! If every one of you were to work 
at these reforms with real energy and enthusiasm, your own 
ingenuity, tact, "mother wit," industry, patience, and per- 
severance would accomplish wonders! But it must be under- 
taken earnestly and honestly. 

" Susie, button your dress," " Katie, tie your shoe," " Mrs. 
B., don't follow the doctor down the hall," and the like, uttered 
in a forceless, half-hearted way — such a method is just so 
much water on a duck's back; it is even worse than useless, 
for by uselessly calling attention to it, it only serves to strengthen 
the brain impression of the particular fault, and it only lets you 



10 NURSING THE INSANE [Chap. II 

delude yourself that you are disciplining the patient and mend- 
ing matters, whereas you have left the condition unimproved, 
plus the fact that you have actually aided the patient to persist 
in undesirable conduct; yet you really wish to aid her to desist. 

How would it do, for example, if, other efforts having proved 
unavailing to prevent, say, a patient from putting butter in 
her hair, you applied to the physician for a small box of vaseline 
for the patient's personal use ? The chances are that this atten- 
tion would please her, notwithstanding her deterioration, and 
that she would take kindly to the substitution — some oil being 
the main thing desired in this connection. The comfort to your 
own olfactory sense by this substitution ought to be enough 
reward, even were there no other consideration. 

It is surprising, too, for example, how in the matter of using 
a toothbrush, a painstaking nurse can inculcate habits of 
tidiness even in the hopelessly demented. She can sometimes 
appeal to a patient's vanity, sometimes mention. what a difference 
clean teeth make in the taste of one's food, or in the influence 
on the breath, or, if none of these avail, she can as a matter 
of routine see that such patients attend daily to this part of 
their toilet just as she should that they attend to their other 
needs, to the bowels, the food, medicine, and exercise; for 
there is a large class of patients in which all these wants have 
to be superintended by the nurse, and to say that a patient 
never brushes her teeth, for example, is no excuse whatever. 
If she does not, the nurse is there to see that it is done, or to 
do it for her when she proves intractable. 

There is no need to multiply examples. Each case calls for 
a fresh application of energy, ingenuity, and perseverance on 
your part, and in just the degree that you show yourself active, 
resourceful, and indefatigable in meeting these trying questions, 
in just that degree will your value be felt as an efficient nurse. 

I always feel that a nurse is honestly willing to better con- 
ditions if she meets suggestions with a cheerful, " I'll try, Doctor," 
instead of that everlasting answer, "It is no use trying — you 
can't do anything with her" By the nurse's willingness to 
cooperate, she puts herself in the right mental attitude to gain 
the victory over the point in question; she has taken the first 



Chap. II] INTRODUCTORY TALK TO NURSES 11 

step necessary — the step of conquering her own indifference 
in the matter. She is therefore in a position to put her wits 
to work, to summon her resources, and to bring about desired 
results. It is the old story of "Til Try" conquering where 
"I Can't" invariably fails. It is incalculable, too, how much 
more interesting and inspiring you will find the work if this 
attitude is taken and persisted in, than it is to jog along in a 
routine way. 

I have seen a new and energetic nurse take charge of a room 
full of chronic patients who had been allowed by a former nurse 
to eat with their fingers, shoving in the food in a most repulsive 
way; in a few weeks' time I have seen that nurse's painstaking 
efforts rewarded by an orderly set of patients decorously feeding 
themselves with spoons from neatly arranged trays, the same 
cases that other nurses had declared could not be made to do 
differently. But this transformation was not effected without 
patience, perseverance, tact, and a careful study of, and atten- 
tion to, each individual patient; for what works well with one 
will often have no effect upon another. 

There is always this point to be kept in mind, too, that by 
your efforts you can prevent less hopeless cases from sinking 
into the dilapidated ways which more extreme ones have adopted. 
The latter patients should furnish a constant warning to us to 
leave nothing untried to prevent such a result. 

There are other duties to be performed for the chronic patient 
besides looking after the bodily health and appearance. Her 
comfort and enjoyment are none the less important because 
fate has deprived her of some, even many, of her faculties. The 
more she has been deprived, the more is it your bounden duty 
to help compensate her for this loss. Her tranquillity, happiness, 
desires, even her harmless whims, should be ministered to as 
far as in you lies, always keeping in mind the patient's good 
in judging how far you can indulge her, and, in addition, the 
greatest good to the greatest number, not, of course, catering 
to the whims of one person to the annoyance of many others. 

Because a patient is deluded and unreasonable, you are not 
excused from taking precautions, or from resorting to expedients 
which might serve to maintain or to bring about serenity of 



12 NURSING THE INSANE [Chap. II 

mind and peaceableness of behavior, even though you cannot 
hope to dispel the delusions giving rise to troublesome conduct. 
Suppose a patient likes to cut out and save favorite poems or 
pictures, or other clippings from the magazines. If she can be 
trusted with scissors (blunt-pointed, of course), there is no 
reason why she should not be allowed to do this. The things 
she saves may be worthless in your eyes, intrinsically worthless, 
perhaps, but think what they mean to her. Think what that 
little bag which contains her sole stock of treasures means in 
her life, you who have your liberty, your friends, your rooms 
with bookshelves, dressers, wardrobes, and places wherein to 
keep belongings! Think, and be careful how you ruthlessly 
destroy or ridicule her poor little possessions ! I know of no 
more pathetic sight in an insane hospital than these pitiful 
little woolen or cotton bags that many of our patients concoct 
out of scraps of cloth obtained by hook or crook, in which they 
store their small belongings, not even in some instances having 
any place to keep them except hanging on their arms by day 
or tied on the bed or tucked under the pillow at night. It is 
the longing for a home, for a place of one's very own, that still 
survives in the beclouded soul — a remnant of individuality 
which we should all respect as far as possible. In every way 
that lies in our power we should seek to individualize each 
patient; keep him alive to his own personality; do not class 
him as one of a mass; he has his individual life to live, his own 
hopes, fears, and desires; his own place in creation; and it is 
our duty at all times to respect this, to help him to appreciate 
it, if, by reason of his disordered intellect, he is in danger of 
forgetting it. Always call patients by name, do not speak of 
them as "he," or "she"; let each feel that he is somebody, 
a particular somebody — not a mere something, grouped in 
a mass and called "the patients." I was touched some time 
ago when a patient who had been with us for several years 
returned from a visit home, bringing with her one of these little 
bags above mentioned. Seeing her cling to it as fondly as ever 
after her sojourn in the world, I made some comment which 
led her to show me the interior of the shabby receptacle. I 
have forgotten what made up the bulk of the things; I recall, 



Chap. II] INTRODUCTORY TALK TO NURSES 13 

among the odds and ends, some letters written by her little 
girl telling of her standing in school; but what impressed me 
most was a withered rose that had been given her years before 
by one of the hospital physicians — carelessly given on his 
morning visit. The discovery of how that chance act — the 
bestowal of the rose — had given to the afflicted one a veritable 
treasure, showed me how little it sometimes takes to make 
patients happy, and how our casual acts and words often carry 
comfort, or alas ! cause distress that we but dimly recognize 
either at the time or afterward. One must, however, consider 
something besides sentiment in this matter. The question 
has its practical side. Some of you, I know, will immediately 
think of patients with a propensity for collecting things, and 
will wonder if I mean that they are to be humored to the 
full extent of these proclivities. Of course not. This is where 
common sense and tact must be exercised, though even with 
such cases I should say, rather err on the side of indulgence 
than of arbitrary prohibition. A certain nurse gets around 
this matter tactfully by permitting collections to be made till 
they reach a considerable size, when the package is tied, labeled 
by the patient, and sent to the office of the superintendent, 
and the patient goes on contentedly accumulating others which 
in time meet the same fate. She knows that when the package 
reaches a certain bulk it must be carried away; she is happy 
in the belief that her treasures are safe, and is so intent upon 
acquiring others that she does not inquire for the old packages 
after they have passed out of her keeping. No harm is done 
in catering to this whim, and the capacious wastebasket relieves 
us of the worthless hoard. 

Sometimes the things saved by patients have a real value 
for them which is difficult for us to estimate unless we can put 
ourselves in their places. I recall a certain patient who years 
ago had some literary ability, various manuscripts of hers 
having been accepted and published in some of the newspapers 
and magazines. Later a mental disorder put a stop to her 
productions ; she was sent here and there to various institutions 
in the East and West, and finally drifted to our hospital. In 
all these vicissitudes she had managed to preserve the printed 



14 NURSING THE INSANE [Chap. II 

articles that to her represented whatever of achievement her 
life of struggle and aspiration had to show. Think what these 
clippings meant to one now hopelessly stranded in a hospital 
for the insane, with only the past for comfort ! Yet a strenuous 
nurse one day, intent on clearing out things, dumped them with 
"other rubbish," as she said, into the waste; before the fact 
could be reported and a search instituted, they were gone past 
recall. The patient's grief at the loss was a painful thing to 
contemplate. The nurse was very sorry when she learned 
the full import of what she had done, but that could not bring 
back the treasured relics to the patient. 

Bear in mind that each person has her individual habits and 
whims, some of them absurd, some troublesome in the extreme, 
some harmless. When they are harmless, humor them. You 
will, by yielding in non-essentials, often win a victory in essen- 
tials, for patients are susceptible to kindness that comes from 
the heart, and honest endeavors to please them and to add to 
their daily comfort will meet answering if feeble echoes in the 
hearts of those whose minds are hopelessly beclouded. 

Think what you are doing in adding even a modicum of 
pleasure to the lives of your unfortunate charges ! What little 
pleasures, what childish enjoyments yet remain for them in 
their cheerless lives — and these are so largely dependent upon 
the offices and the spirit of the nurse under whose care they 
are placed ! The friends of our patients can do much to relieve 
their unhappiness, the physicians can do perhaps still more 

— alas ! more than we do do, each of us, if honest, must admit 

— but the nurse, whose association with the patient is so direct, 
so constant, and so intimate, has it in her power to do more 
than all others in this line. 

It needs but a little concentration of our thoughts upon this 
subject to convince each of us that he is in duty bound to con- 
tribute his share of sunshine to these beclouded lives, debarred 
as they are from the many pleasures that come to persons with 
sound minds. 

There is a trite saying to the effect that we must take things 
as we find them. True, but we are under no restrictions to 
leave them as we find them, and this is the thought I wish to 



Chap. II] INTRODUCTORY TALK TO NURSES 15 

impress upon you at the close of our first talk together. Let 
us be discontented to this extent — that each of us turns his 
attention upon his own field of work, sees things as they are, 
and henceforth earnestly resolves and undertakes straightway 
to make them better than they are. 

Waste no time or energy in thinking, " If I only had ward , 

or ward , I would show that I could do something." Right 

here, in your own field, are the battles you are called upon to 
fight with disease and delusion. The enemy's ranks are all 
around you; one must contend with indifference and sloth; 
with depression and stupefaction; with long-standing habits; 
with perverseness, malice, error, blindness; with uncleanliness 
of deed, word, and thought. You are, in fact, encompassed by 
a large army of evil passions uncontrolled, with all their un- 
certain and dangerous tendencies, but you are enlisted against 
them, and so long as you stay in the service, it is your duty to 
rally your forces and to rout the offenders. Such as cannot 
be routed must be subjugated and converted into peaceful, 
law-abiding subjects — no easy task, but who wants an easy 
victory ? 

We hear a great deal about the spoils of war, the victor's 
crown, and the glory of the conqueror on other battle fields. 
I know the soldiers to whom I am talking, and I believe that 
most of you are looking for no spoils, no badges of honor, and 
no glory as of trumpets and drums. I believe that most of you 
are working for something besides glory, for something besides 
monthly wages. Even if this latter motive was chiefly what 
actuated you on entering the service, I think it is otherwise 
now, though of course no sensible person is indifferent to the 
compensation he receives for work, and few of us are so situated, 
or for that matter so philanthropic, as to engage in work of this 
trying kind without wishing to receive due compensation for 
services rendered. And, as I said just now, notwithstanding 
the question of wages was what decided you to take up the work, 
I think there are few who remain long in the service that do not 
develop other and higher interests. The average young man or 
woman with a healthy body, a kind heart, and a helpful dis- 
position, cannot long have the care of these dependent, trying, 



16 NURSING THE INSANE [Chap. II 

often exasperating patients, without developing a tender feeling 
toward them, and an earnest desire to make up to them, so 
far as one can, what fate has denied them — a sound mind in 
a sound body. 

I have watched you at your work — a work so arduous and 
so trying that I have often marveled at the patience and the 
fortitude displayed in continuing in it, and would still marvel 
even if your compensation were doubled, and the appreciation 
of your services more clearly, definitely, and frequently expressed. 
I have seen you diligent in the business before you, fervent in 
the spirit of helpfulness to those intrusted to you, showing 
good will to your associates, and obedience and respect to those 
in authority. I have seen you perform the most trying tasks 
a human being could be called upon to do, in comparison with 
which the cleansing of the Augean stables would be less her- 
culean than some of your daily duties. I have seen you patient 
under the most malicious abuse, modest in the midst of ob- 
scenity, courageous in the midst of discouragements, and brave 
in the face of hourly dangers before which strong men would 
quail, and which they would refuse to face a second time. All 
this and more I have noted, and I make these suggestions, 
with others that are to follow, not because I underrate your 
devotion and your self-sacrifice, but because I wish to help 
those of you who fall short in some of these particulars, and to 
stimulate and encourage all of you to renewed efforts, to in- 
creased usefulness, and to richer results than have hitherto 
crowned your efforts. 



CHAPTER HI 

RULES TO OBSERVE WHEN ON DUTY 

Every nurse or attendant when on duty must wear the pre- 
scribed uniform. 

Each nurse is expected to report for duty at the hour desig- 
nated by the hospital regulations, and to remain on duty con- 
tinuously until the hour appointed for her release, except when 
excused either by the supervisor or the physician. A nurse 
must not absent herself from the ward, unless sent away in 
the discharge of some duty, without previously obtaining the 
permission of supervisor or physician. A nurse is not on duty 
when sitting in her room. During her hours for duty, even if 
her room is on the ward, her place is with the patients. 

One of the first duties of the nurse is bodily cleanliness and 
tidiness. A nurse whose self-respect is not sufficient to cause 
her to be fastidiously neat in person and dress, can scarcely 
hope to inculcate neatness in others. It is not always possible, 
in doing certain work early in the morning, to be in the im- 
maculate state that all hospital nurses are expected to be in 
between 10 a.m. and 4 p.m., but it is never permissible for a nurse 
to come on duty without her body at least being clean and 
wholesome, and her hair neatly brushed and dressed, even though 
for the earlier work it is necessary for her to don a uniform not 
entirely fresh. It is permissible for the nurse to exercise econ- 
omy in material and in laundry work by thus using her old 
uniforms when doing certain tasks, but when arrayed for her 
day's work her gown should be fresh and well mended, however 
old it may be. 

A few words are necessary about the dressing of the hair. 
A nurse is not dressed in good taste when she has so followed 
a prevailing mode of hair dressing as to make her cap look like 
c 17 



18 NURSING THE INSANE [Chap. Ill 

a ridiculous appendage, instead of, as it should be, the crown- 
ing insignia of her office. Dress your hair becomingly always, 
follow the style in hair dressing (if it suits your face) in so far 
as you can do so and still have your appearance, with your cap 
on, what it should be; but if you cannot do this without letting 
your cap be perched upon your head in an unseemly way which 
shows it to be there only because it has to be, reserve this elabo- 
rate hair dressing until your afternoon or evening out. While 
on duty, let your hair be neatly and inconspicuously arranged. 
I was much chagrined once in accompanying a certain president 
of the Commission in Lunacy through the wards to have him 
ask me why, as woman physician, I had not influenced some 
of our nurses to a decent, fitting arrangement of the hair; he 
instanced one or two, whose hair was dressed in an extreme 
and unbecoming fashion, as looking like Circassian girls or 
Feejee Islanders. I could but acknowledge that his criticism 
was merited. Fancy collars and neckwear, hair ornaments, 
and jewelry are out of place on a nurse when in uniform. The 
nurse's pin and the badge on the sleeve are the only ornaments 
it is permissible for her to wear. 

The foot gear of the nurse is an important point for con- 
sideration. I believe if all nurses, when on duty, could be per- 
suaded to wear shoes with low, broad heels — and rubber heels 
at that — and soles of considerable thickness, the ease and 
comfort thus secured would add to their efficiency, as I know 
it would to their health and happiness. A nurse with tired 
feet, with corns and bunions, with tight shoes and thin soles, 
can never hope to be a good-natured, willing, or efficient nurse. 
The nurse's shoe should be as much a part of her prescribed 
uniform as is her gown, cap, or apron, since comfortable foot 
gear influences the willingness and temper to a surprising de- 
gree. Rubber heels, too, aside from the comfort derived from 
them, secure that noiseless tread so much to be desired in the 
nurse. 

Nurses and attendants are, of course, not to wear or use arti- 
cles of clothing belonging to the patients or to the hospital, 
unless, in the latter case, such articles are given them for wear 
or use by the authorities. 



Chap. Ill] RULES TO OBSERVE WHEN ON DUTY 19 

Nurses are expected to set a good example to patients, not 
only in dress, but in conversation and conduct as well. 

The use by nurses or attendants of intoxicating liquors on the 
premises is a cause for dismissal from the service. It is also 
against the rules for male attendants to smoke anywhere within 
doors, except in the places designated for that purpose. It is 
hardly necessary to say that a female nurse or attendant addicted 
to the use of alcoholic stimulants or tobacco will scarcely remain 
long in the institution. While not wishing to discuss the dis- 
gusting habit of tobacco chewing, or the silly, disfiguring one of 
gum chewing, I will merely state that a nurse or an attendant 
who has so little respect for himself or herself as to indulge in 
such habits, should at least be taught by the supervisor to respect 
the patients and the physicians enough to refrain when on duty. 

No patient shall be furnished with intoxicating drinks or drugs 
not prescribed by a medical officer of the institution. Employees 
are forbidden to deliver to or receive from a patient any letter, 
parcel, or package, without the consent of a medical officer. 

The highest standard of hygienic housekeeping shall be at all 
times maintained on the wards — visible and invisible cleanli- 
ness — a cleanliness that looks after dark corners and upper 
shelves, a cleanliness that removes the accumulations from 
behind the radiators and that " sweeps under the mat." 

In connection with cleanliness we may consider the adorn- 
ment of the wards. The aim of all modern hospitals for the 
insane is to make the wards and rooms as attractive and home- 
like as possible; to this end much can be done by the concerted 
action of the nurses : first, in caring for the property that the 
State provides, in promptly attending to its repair, in guarding 
against its destruction by the exercise of systematic foresight; 
and, in addition to that, in enlisting the interest and coopera- 
tion of the patients in beautifying and adorning the wards. 
Throughout the institution there are many patients who could 
contribute some of their handiwork. Some can paint, others 
can embroider stand covers; some can weave very effective mats, 
and useful and ornamental baskets; some can make rugs, or 
sofa pillows, or hemstitch bureau covers; others can fashion 
artistic book shelves, or wall cabinets, or picture frames — these 



20 NUKSING THE INSANE [Chap. Ill 

are only a few of the things, enough to suggest others if you are 
on the lookout to utilize the dormant capabilities of your pa- 
tients. By so doing you serve two important ends : you beau- 
tify your wards, giving to each its own individuality, and you 
furnish occupation for the patients. The last consideration 
cannot be too highly commended, as it may prove one of the 
most potent means of keeping patients from drifting into de- 
mented conditions, devoid of all healthy and enlivening interests. 
And even if it does not effect this, it will do much to make cer- 
tain patients feel a personal share in the place which is perhaps 
destined to be their home the rest of their days. 

You can always enlist nature's aid in the adornment of the 
wards. There are but few times in the year when you cannot 
find something in the way of decorations that will give a pleas- 
ing touch to the rooms and halls. Pussy willows, cat-tails, and 
the various grasses and evergreens, the wild flowers of spring, 
summer, and autumn, autumn leaves, wild clematis, bitter-sweet, 
and alder berries, and many other beautiful berries, can be 
gathered, and used effectively if taste and thought be given to 
their arrangement in form and color. These will serve most 
satisfactorily as decorations, as well as souvenirs of pleasant 
rambles that you and your patients take when gathering them. 
There is still another use they serve — they bring the healthy 
spirit of outdoors nearer to your daily lives. Greenhouses, too, 
are valuable aids in the adornment of the wards. Requests for 
decorative plants will usually be willingly granted if you exercise 
a proper supervision in preventing their destruction. On some 
wards the nurses say it is no use trying to keep such adorn- 
ments. I grant that the attempt is sometimes discouraging, 
but I believe there is no ward where this cannot be effected 
in time if the nurses in charge are willing to follow the matter up 
and take a little extra pains to bring it about. For on wards where 
nurses aver that it cannot be done are patients of the same class 
as those on other wards where it is done, and where the nurses 
and patients have learned to take pride in the ward adornment. 

Just a word about withered flowers. These are often allowed 
to remain in the rooms long after their beauty is gone, sometimes 
from carelessness on the part of the nurse, at others perhaps 



Chap. Ill] RULES TO OBSERVE WHEN ON DUTY 21 

from a patient's reluctance to throw away flowers which have 
been sent her. Nothing is more beautiful than fresh flowers, and 
few things are more unlovely than withered ones; so remember 
to keep the water fresh in their receptacles, care for the flowers 
as well as you can, but when their beauty is gone, quietly con- 
sign them to the waste. When decay has set its mark upon 
them, esthetic and sanitary considerations combine to call for 
their removal. 

While on the subject of disagreeable odors, I wish to emphasize 
the desirability of having the hospital departments free from 
bad odors and disagreeable sights, especially at meal time. 
The hospital wards should, of course, receive careful and syste- 
matic attention to ventilation at all times, but especially is it 
desirable, when patients are eating, that unpleasant odors be 
reduced to a minimum. In order to effect this, a little foresight 
is necessary. Unclean patients must be taken up and cared for 
(and the hospitals carefully aired) long enough before meals to 
insure against offensive discharges vitiating the atmosphere 
during the meal hour. The doors to the water sections should 
be kept closed, patients who are disgusting in habits and mode 
of eating should be grouped together and, when possible, screened 
from the sight of others who would be unpleasantly affected by 
their unsightly ways. Remember that by considering the es- 
thetic feelings of patients you help to preserve these feelings, 
and thus help to prevent your charges from drifting into the 
deplorable condition in which this sense is abolished. 

It is in the highest degree desirable also to avoid unnecessary 
noise on the wards, both by day and night. There are many 
ways in which the nurse can reduce noise on the wards if she 
will. In the first place, by wearing rubber heels and cultivating 
a noiseless tread. A sensitive patient during convalescence once 
spoke as follows concerning a well-meaning nurse who had been 
an irritating source of discomfort to the nervous invalid: "I used 
to feel," she said, "as if her heels were going right through my 
brain. She would race up and down past my door, shouting 
her orders, jangling her keys, and pounding her heels till I got 
to hate the sight and sound of her." The quiet turning of the 
key in the locks, the avoidance of unnecessary jangling of chain 



22 NURSING THE INSANE [Chap. Ill 

and keys, the gentle closing of doors and windows, the prompt 
attention to bells (telephone, door, and waiter bells), so that 
they need not keep on ringing, the oiling of creaking hinges, the 
attention to flapping window shades, the avoidance of rattling 
trays and dishes, the careful moving of beds when necessary to 
move them, the low and gentle voice cultivated by each nurse, 
the avoidance of hurry and bustle even when haste is necessary. — 
these are a few of the things nurses can do to diminish noise on 
the wards. Noise in itself irritates both nurse and patient, 
often without either knowing the cause of the discomfort; the 
irritability induced begets more noise in those whose self-control 
is weak, and a regular bedlam is established which might have 
been avoided had a little extra care been exercised in the begin- 
ning. Much can be done to diminish the noise of the patients, 
too. In the first place, we need to keep in mind that noise is 
misdirected energy — pent-up energy rinding an outlet. All 
nurses have noticed how much noisier patients are on rainy days, 
when they have had no outdoor exercise, than at other times. 
With this in mind, it may be seen why efforts should be persistent 
in the matter of getting every suitable patient out for exercise 
as long and as often as you can. Energy will then be expended 
in beneficial muscular activity out of doors, instead of in bicker- 
ings and railings within. On days when it is impossible to get 
the patients out, if they are interested in some kind of exercise 
on the hall — arm gymnastics, a bean-bag contest, even a pillow 
fight, or some such thing, the time and trouble will be well re- 
paid; restlessness and irritability will give rise to a pleasant 
feeling of fatigue, and to general good spirits, perhaps to a little 
good-natured hilarity, but is not that far preferable to ill-natured 
bickerings and contentions ? Certain patients become noisy not 
so much from want of exercise as that some one has offended or 
interfered with them. It is your duty to study your patients, 
their whims, and their antipathies, seek to obviate dissensions 
among them by being on hand and preventing the beginnings of 
quarrels between antagonistic ones. You can, by so doing, nip 
many a quarrel in the bud, cut short an altercation that would 
otherwise go on to high words, blows, and dangerous assaults. 
Helpless and dependent patients should be especially safeguarded 



Chap. Ill] RULES TO OBSERVE WHEN ON DUTY 23 

from irascible and violent ones. You are there to quell distur- 
bance, to guard against abuse and violence. When these occur 
on your wards, it usually shows that the supervision has not been 
as thorough as it should have been. 

Whenever a physician enters a ward, all the nurses and attend- 
ants are expected to rise if sitting, and the nurse in charge is to 
accompany him through the ward, and hold herself in readiness 
to give information concerning the patients in her care. Should 
the head nurse not be present or in sight, any nurse in sight 
should accompany the physician until relieved by a senior or by 
the charge nurse. A tactful nurse will know when to absent 
herself from the room and give patient and physician an oppor- 
tunity to converse alone. Yet she should remain within calling 
distance in case information is required of her. 

A nurse should be conscientiously obedient and loyal to the 
hospital physicians. If she cannot be so, she had better find 
employment elsewhere, for even if she does not commit the 
grave error of criticising the physicians to other nurses, or to the 
patients, her antagonism and insubordination show themselves 
in other ways, and her influence for good is thereby greatly im- 
paired. Such a nurse may be tolerated, but is not valued. It 
is not to her that one goes for an honest statement, it is not in 
her that one can feel confidence. 

The nurses and attendants in each division are under the 
direction of the supervisor of that division. The supervisors 
act as agents between the medical officers and the nurses and 
attendants. Requests and reports should ordinarily be made 
through the supervisors to the medical officers, and directions, 
when practicable, transmitted by them from the medical officers 
to the nurses, concerning the general care of the patients and the 
management of the wards. Direct communications to the head 
nurse are often necessary from the visiting physicians (unless the 
supervisor is particular to time her visits to the wards at the time 
that the physicians are making their rounds), as many matters 
arise that require detailed instructions to those in immediate 
care of the case, which might suffer in the matter of thorough- 
ness, accuracy, and promptness if the instruction were to pass 
through a third person. 



24 NURSING THE INSANE [Chap. Ill 

There are certain duties that nurses owe to one another, 
certain unwritten rules of fairness and kindness that should 
invariably be observed. Personal neatness and tidiness in your 
room and with your belongings, and a consideration for the 
comfort of your associates, will render you an unobjectionable 
roommate, even if you do not happen to have the qualities of 
mind and disposition that make you actually congenial and 
companionable with [that particular roommate. This considera- 
tion should extend to matters of room arrangement, order, ven- 
tilation, scrupulous respect for, and non-interference with, each 
other's belongings and tastes, regard for the hours of sleep and 
rest, and your share of contributing to the order and cleanliness 
of the room. 

On the wards, respect for your superior nurse, a willingness to 
help her and the other nurses in every way that you can, a real 
sharing of the burdens and a cheerful working together, patience 
with the weaknesses of fellow-nurses, avoidance of discussing 
those weaknesses, refusal to gossip about associates or other 
employees, or patients, or officers, a helpful spirit toward new 
and inexperienced attendants, and forgiveness toward un- 
friendly ones, even those that you feel may have willfully wronged 
you — these are some of the duties you owe to yourself and to 
one another. 

Let your conduct to the patients' relatives and friends be uni- 
formly courteous and considerate. Many of them are very try- 
ing, more so even than the patients, but remember that they 
deserve your forbearance. Often they come to the hospital in 
fear and trembling, distressed by the thoughts of their friends 
being in an institution of this character. They are sometimes 
nervous and apprehensive, some are fussy and unreasonable, 
others are perhaps haunted by the fear that a similar fate awaits 
them. Remember that many are full of fears and prejudices, 
with the old-time ideas that these hospitals are places of deten- 
tion and cruelty. They are all unaware of modern methods of 
treating the insane. They will often beg you to be kind to their 
loved ones as though that were not the rule. Do not let this 
appeal arouse your indignation at the reflection on yourself that 
it implies. Of course you mean to be kind, but they do not 



Chap. Ill] RULES TO OBSERVE WHEN ON DUTY 25 

always know it; they do not know you; they are harrowed by 
anxiety, perhaps by false statements or misrepresentations from 
the patients. Instead of resenting their appeals, do your best 
to remove their anxiety. 

Nurses are not expected to discuss the patient's condition or 
prospects with the friends or relatives. On no account are they 
to express an opinion as to the outcome of a case, nor as to when 
a patient will probably be well enough to go home. Friends will 
often ask these and other questions, but the nurse's duty is to 
refer them invariably to the attending physician. A nurse may 
express hope of improvement, and may tell of good behavior on 
the part of a patient, or may mention things in which the patient 
shows an interest ; she may offer to furnish a list of needed cloth- 
ing (which should, however, first be submitted to the supervisor 
and receive her sanction), but she should, as a rule, confine her 
conversation to these lines. She is overstepping her rights when 
she ventures opinions or suggestions to the patients' friends, 
except such as have been enumerated. We are constantly meet- 
ing with this infringement of the rules. The friends, in talking 
with the physicians later, say, " Why, her nurse said she could go 
home at such a time," or, "Her nurse said she could see no 
reason why she is kept here," or, " Her nurse said this or that," 
often faulty opinions advanced which the physician is in the 
embarrassing position of having to correct. 

Nurses and attendants are not allowed to visit or to hold 
correspondence with relatives or friends of patients while the 
patients are in the institution. All letters regarding patients 
received by nurses are to be referred to one of the medical officers. 
It is a grave misdemeanor for a nurse or other employee to give 
to any outsider the information that a given person has been or 
is confined in the institution. And if the fact is already known, 
and the nurse or other employee is approached with questions 
as to the condition or prospects of any patient, the invariable 
reply should be that it is strictly against the rules to discuss 
the condition or affairs of any patient. Such replies should be 
made in a tactful way, at the same time that the inquirer 
is given to understand that information on these topics can 
always be obtained by appealing to the officer in charge, 



26 NURSING THE INSANE [Chap. Ill 

provided the inquirer is one who has a right to such informa- 
tion. 

No male employee shall enter or carry keys to parts of the 
hospital occupied by women, except by permission of the super- 
intendent. But male attendants, workmen, and other em- 
ployees are from time to time engaged in work on the women's 
wards and in the hospital departments. A nurse should re- 
spect herself and her calling enough to maintain a pleasant 
but dignified demeanor toward all such outsiders, going about 
her duties as diligently as though she expected the medical 
officers on the hall at any minute, watching her patients to see 
that no unseemly conduct or conversation that she can possibly 
prevent, takes place, and absolutely refraining from taking such 
opportunities for social chats with the ones sent there to do 
certain work. 

It is also the duty of nurses and attendants to exercise especial 
care when men visitors are on the women's wards, and women 
visitors on men's wards, to prevent if possible any improper 
exposure, indecent talk or conduct, or chance of any behavior 
either on the part of patients or visitors that should be prevented. 
Failure of proper supervision in this matter has sometimes led 
to unfortunate results. In rare instances injudicious and un- 
scrupulous visitors have been known to leave drugs, stimulants, 
and dangerous weapons with patients, and in not a few instances 
scrutiny is necessary to prevent unseemly behavior on the part 
of visitors as well as of patients. 

Nurses who are sent to the storeroom, laundry, or other places 
on errands, are guilty of violation of the rules, as well as of bad 
taste, when they loiter around stairways and talk with the 
employees whom they chance to meet. Persistence in con- 
duct of this kind should be reported to the medical officers by 
the charge nurse, if her remonstrance prove ineffectual. 

All medicines are to be kept locked in the desks or cupboards 
provided for such purposes, and are to be dispensed regularly 
and faithfully as directed by the physicians. In no instance is 
a patient to be permitted to have her medicine in her room and 
take it as she wishes. This is a direct violation of the rules of the 
hospital. On no account is a medicine prescribed for one patient 



Chap. Ill] EULES TO OBSERVE WHEN ON DUTY 27 

to be given to another whom the nurse considers to be suffering 
similarly, unless such medicine is directed to be so given by the 
physician. On no account is a nurse to give medicine to a patient 
which has been prescribed for a previous similar attack of illness, 
even though some of it is accessible on the ward, unless the 
physician sanctions this procedure. On no account is the nurse 
to fail to give the medicines prescribed, nor shall she allow her- 
self to insinuate or to remark that the medicine does no good, or 
that the patient does not need the medicine, or that it aggravates 
the patient's condition. On no account is a nurse to give or to 
recommend to a patient any wash or salve or hair dye or corn 
plaster or anything of this nature without the express permission 
of the physician in charge, or some other medical officer acting 
in his stead. Except in extreme emergencies a nurse must not 
give alcoholic stimulants to a patient without a physician's order, 
and then it should be immediately reported to the physician, 
since a condition requiring stimulation probably also requires 
the immediate attention of the physician. In every instance 
that a patient refuses to take the medicine prescribed, the fact 
should be reported to the medical officer. 

Great care is at all times necessary in watching over the medi- 
cines, disinfectants, keys, matches, knives, scissors, and any 
articles that could be used as weapons. A nurse should make it 
an invariable rule to try every door or drawer after locking it, so 
that the action becomes automatic; then she will not be in danger 
of sometime leaving these places unlocked, when in haste or 
preoccupied. She must always bear in mind that many things 
are intrusted to her care which, if unguarded, might be eagerly 
seized upon by depressed and suicidal, or mischievous or violent 
patients, whose use of them might result in incalculable harm to 
themselves or others. 

It is the duty of the supervisor to instruct new nurses in all 
hospital rules, and especially in the matters just mentioned; and 
it is the duty of the nurse in charge to exercise constant care to 
see that these instructions are obeyed. Any negligence in the 
care of the medicines, the knife drawers, the locking of dumb 
waiter doors or clothes chutes, the care of keys, or any other 
precautions whereby patients are prevented from harming 



28 NUKSING THE INSANE [Chap. Ill 

themselves or others, should be promptly reported to the super- 
visor. A nurse in charge, even if only temporarily so, who fails 
to report such negligence, or who fails to report any attendant 
or nurse who is guilty of ridiculing or unkindly or cruelly treat- 
ing a patient, lowers herself to the level of the one committing 
the offense. Many nurses have a mistaken notion of its being 
"mean" to report a fellow-nurse for offenses. They do not 
wish to be classed with those who tell tales. But this is a differ- 
ent matter entirely, and it seems as though any reasonable per- 
son ought to be able to see the difference between the rather 
questionable practice of spying out and reporting mischief and 
petty misdeeds, and the honorable one of reporting any instance 
coming to your knowledge of a helpless insane patient being 
ridiculed, abused, or neglected by one trusted to care for that 
helpless person. Where does your honorable conduct lie if, by 
your silence, you join your strength to that of the unscrupulous 
one, two against one, and that one helpless and incapable per- 
haps of physically or mentally defending himself? The sooner 
you divest yourselves of such notions about honor, the sooner 
you will be more worthy of the trust placed in you. 

Mechanical restraint must never be applied without the 
written permission of one of the medical officers. In an emer- 
gency this permission may be first obtained over the telephone, 
but the nurse must later obtain a written permission for the 
same, by applying at the office as soon as the patient is in restraint, 
or, in case the necessity occurs at night and a verbal permission 
is given, by requesting the written permission early in the 
morning, if the physician overlooks the rule of sending it to the 
ward. These reports must also have the nurse's signature, they 
must distinctly state the nature of the restraint, the time that 
restraint has been employed, as well as the necessity for its 
application, and they must be regularly sent to the office for filing. 

No patient shall be locked in a room (which constitutes seclu- 
sion, if occurring in the daytime) without the written permis- 
sion of a medical officer, except in unquestionable emergencies, 
and even then it shall be immediately reported to the physician, 
with the reason given for the urgency of such a measure. A 
nurse who locks a patient in a room for certain hours of a day.. 



Chap. Ill] EULES TO OBSERVE WHEN ON DUTY 29 

taking her out when she thinks the physicians are likely to come 
on the ward, is guilty of direct violation of the rules and of 
unpardonable deception besides. 

There are countless things to be observed concerning the 
nurse's conduct toward and her treatment of patients; only a 
few can be outlined here ; others will be mentioned in speaking of 
the various details of nursing. 

The nurse needs to remember at all times that her first duty 
is the welfare of the patients. I wish to make this point em- 
phatic. Why do we wish the nurse neatly and suitably attired, 
the wards hygienically conducted, the work systematized, the 
food properly served, the bathing carefully and considerately 
managed, the patients taken out for exercise, sent to amuse- 
ments, and set to work ? For the good of the patients. Cleanli- 
ness, law and order, system, hygiene — all are to this one end. 
Think, then, how you fail in the end, if you lose sight of it, so 
intent are you on the means to the end ! To illustrate : It is a 
rule of the hospital that the wards shall be in order, the patients' 
daily needs attended to, the nurses properly uniformed, at 10 a.m. 
Why ? Merely for the sake of the medical officers who formally 
visit at that hour ? No ; but rather for the good of the patients. 
Yet many nurses forget the end which should be kept in view, 
and, in their desire to accomplish all that must be done, often 
really disregard the good of the patient, or her comfort. I 
have seen this repeatedly in going in the hospital departments 
before the regular visiting hour. I have seen patients rudely 
and unnecessarily exposed while being cared for, others allowed 
to sit on a commode or closet, insufficiently clad, in cold weather, 
and I have seen patients' beds jerked about in a way that would 
seriously disturb a well person — so intent was the nurse on 
hurrying to get her work done by the time for " rounds." Another 
instance of overlooking the end to be attained is where a patient 
is set to work, perhaps in the sewing room or laundry, and prov- 
ing herself excellent help, is kept there morning and afternoon, 
regardless of the need of rest, or of being taken out for exercise, 
or of going to amusements, if such occur in the daytime. This 
you will readily see is all wrong, yet such thoughtlessness or 
mismanagement is discovered from time to time. We wish a 



30 NURSING THE INSANE [Chap. Ill 

given patient to work because it is good for him or her; that 
is the primary reason. The work to be accomplished should 
always be a subordinate consideration; it should never become so 
prominent that other means of benefiting the patient are lost 
sight of. Patients shall not be employed on private work for 
employees without the consent of a medical officer, and no em- 
ployee is allowed to trade or bargain with patients. 

A practice that is reprehensible in the extreme is the habit 
that some night nurses have, unless closely supervised, of getting 
their patients up at an unseasonably early hour so that they can 
get the work done early and secure the help of patients who are 
perhaps willing workers simply because they are too demented 
to rebel against being routed out at that hour. This practice 
cannot be too strongly condemned. The legitimate hour for 
rising, the hour that has been found necessary by the hospital 
authorities, is in itself an early one, and no patient should be 
deprived of the allowance of sleep afforded by the hospital regula- 
tions. Even if a patient cannot sleep, she should be permitted to 
enjoy the rest in bed that is hers by right; and, in acute cases, 
this robbing her of even five minutes of needed sleep is a really 
criminal thing on the part of a nurse, for it is jeopardizing the 
chances of recovery. This question will be discussed further 
when considering the duties of night nurses and the importance 
of sleep in the upbuilding of a patient's health. 

In some wards I have seen a semblance of order that is all too 
obviously for the benefit of the visiting physician — an outward 
order, the floors clean, the beds neatly arranged, the nurses tidy, 
but the bed patients themselves often bearing evidences of 
neglect — neglect of some of the details of the toilet. I do not 
refer to disheveled hair, for I well know that many insane 
patients will look untidy, though attention is given to them 
repeatedly during the day and the hour, but I refer to such 
things as the care of the nostrils, the corners of the eyes, the 
teeth, the nails (toe nails as well as finger nails), and the care of 
other parts of the body that we trust the nurse to attend to daily. 
There is an unmistakable something apparent in certain wards 
where these details are not systematically attended to; the 
patients do not look clean, they do not smell clean, they are not 



Chap. Ill] KULES TO OBSERVE WHEN ON DUTY 31 

clean. It may be safely argued, too, that if a nurse neglects parts 
of the body which can be seen, she will be still more negligent 
of those parts which are only subjected to occasional investigation 
by the physician. 

Patients are to be treated uniformly with respect and kind- 
ness. All your dealings with them should be straightforward 
and truthful; they are not to be wheedled into doing things by 
false promises, nor frightened into certain lines of conduct by 
threats of what will befall them if they fail to obey. They must 
never be ridiculed or teased. You should study your patients 
as individuals, seek to learn their needs, encourage them to help 
themselves and one another, converse with them, draw them out 
about their tastes and their former interests, but do not ask 
them searching questions or pry into their history. That is 
the province of the physician. Do not argue about, ridicule, or 
discuss their delusions with them. Try to make your wards 
homelike. Let your patients feel that their rooms are for their 
comfort. While we wish the rooms to be tidy, it is not at all 
desirable that they preserve that " picked up" appearance that 
strikes a chill of desolation to one's very marrow, as though one 
took no comfort in them, and the rooms were on dress parade 
from morning till night. Let the books and papers and the 
work of the patients lie around the room in an orderly disorder, 
if we may so speak, let patients lie on their beds if they wish a 
nap, or wish to rest; that is what beds are for, although, of 
course, reasonable care should be exercised in keeping counter- 
panes clean, and in training the patients to make the beds tidy 
after having risen from them, so that the rooms do not present 
a disorderly appearance. Let patients close their doors (when 
they are to be trusted) if, at times, they desire a little seclusion 
and quiet, but see that the doors are left open at the hours when 
the physicians are expected to make regular rounds. In short, 
allow patients all the liberty possible consistent with safety and 
with the rules of the institution. 

Pay especial attention to new patients and to those recently 
transferred from other wards. Seek to make them feel at home; 
explain the rules and customs in vogue in your department. 

Maintain vigilance toward those who are depressed and sui- 



32 NURSING THE INSANE [Chap. Ill 

cidal, and those likely to attempt escape, but do this without 
letting them feel that you are watching them. Too obvious 
surveillance is irksome and unnecessary. 

Be attentive to the needs of your patients in the matter of 
clothing and belongings, adapt the changes to changes in the 
weather, remember that poorly nourished persons need to be 
more warmly clad and require warmer quarters in the dormito- 
ries and hospital departments than the robust ones. 

Every ward patient should be bathed at least twice a week 
and oftener if necessary, and every bed patient in the hospital 
departments should receive a daily sponge or spray bath. The 
underwear of every patient shall be changed once a week and 
oftener, as necessary. 

It is the duty of the nurse in charge to see, or to have her 
assistants see, that all her patients attend daily and regularly to 
the bowels and bladder, to the brushing of their teeth, and to 
the scrupulous cleanliness of their persons. If they are inca- 
pable of attending to these things, it becomes the nurse's duty 
to look after them regularly. I do not mean, of course, that the 
charge nurse shall give each patient in her service her personal 
attention in these matters, but that she shall assign the care of 
each patient to some of her helpers whose duty it is to look after 
these particulars. 

Male patients who do not wear a full beard require shaving 
at least once a week, and the beard, mustaches, and hair must 
be kept clean and neatly trimmed. 

On no account is a patient to be deprived of her meals unless 
so ordered by the physician. The utmost care should be ex- 
ercised in serving the meals both in the dining rooms and on the 
trays; to see that the food is served temptingly; that the in- 
dividual needs and preferences of the patients are supplied as far 
as possible ; that the special diets reach the ones for whom they 
are prescribed; also that the changes made in diet are promptly 
recorded on the diet lists; and that transfers of special diets 
are effected when the transfer of the patient is made to another 
ward. 

Nurses must not receive visitors on the wards without per- 
mission, neither may they go to any ward, other than the one to 



Chap. Ill] RULES TO OBSERVE WHEN ON DUTY 33 

which they are detailed, without permission from the charge 
nurse, or supervisor, or one of the medical officers. 

Cooking is to be done only in the kitchen and washing only in 
the laundry, except by special permission of a medical officer. 

All complaints of illness or injury should be promptly reported 
to a medical officer. Serious illness, injury, or unusual excite- 
ment or disturbance occurring at night should be reported to 
the ward physician or to one acting in his stead. 

In all cases of violence, struggle, or resistance, call sufficient 
help to admit of handling the patient so as to avoid bruising or 
injuring him. 

Nurses must wear their keys out of sight and out of reach of 
the patients. 

Nurses must never give their keys into the keeping of another 
person, and on leaving the premises must deposit their keys in 
the place arranged for them, and call for them in person on their 
return. 

Nurses are on duty when accompanying patients to chapel or 
to entertainments, and when out for exercise, as much as when 
on the wards, and at such times should make their first object 
the care and pleasure of their charges. When accompanying 
patients who are employed in some work, it is the duty of nurses 
to assist and direct such work, and not to stand or sit idly by 
and order the patients about. 

The conduct of certain attendants at amusements is often 
gravely criticisable. The rude behavior occasionally noted 
could never take place if each attendant kept in mind the duty 
of setting a good example to the patients. It is an actual fact 
that patients often set good examples to the attendants by their 
courteous attention and their appreciative applause. It is only 
rarely that the patients whisper or titter or do anything to annoy 
others who are trying to listen to recitations, singing, or other 
efforts to entertain the audience. 

In cold weather, when taking patients out for exercise, it is 
incumbent upon the nurses to see that the patients are properly 
clad, and in severe weather it is very important to have a care that 
patients do not freeze the nose or ears or get the fingers frost- 
bitten. 



CHAPTER IV 

THE RECEPTION OF PATIENTS 

It is a matter of great importance to establish a good first 
impression upon each patient admitted to the institution. I 
wish the importance of this could be felt more keenly by all who 
have to do with each case — by the ushers who greet the patient 
at the main entrance, by the physician who receives him, by the 
supervisor who conducts him to the ward, and by each nurse 
who comes in contact with him as he enters upon his strange life 
within our walls. 

Reflect how often patients arrive after having been deceived 
by their friends — and even in some instances by physicians — 
led to think they were going to a boarding place in the country, 
or to a sanitarium, and consequently, when undeceived, starting 
in their life here in a state of distrust toward their best friends 
— the ones they have confided in heretofore. Is it any wonder 
that they look upon everything they encounter in their new life 
with suspicion? Or if, as it always should be, the truth has 
been told them as to their destination, think how many come 
unwillingly, even resistingly, and full of morbid suspicions and 
forebodings ! Without proper insight into their own condition, 
many are incapable of understanding the necessity for such a 
step, and naturally rebel against it. Others whose insight is 
such that they acquiesce in coming, nevertheless come with dread, 
with fear and trembling, though knowing that it is the last resort 
left them. 

Much can be done, at the outset, to undo the effects of the 
deception that has been practiced upon patients, and to allay 
their natural suspicions and fears. 

Remember the lasting power of first impressions; let your 
first thought be to make the patients feel that they have fallen 

34 



Chap. IV] THE RECEPTION OF PATIENTS 35 

among friends, and remember that in just the degree you cause 
them to feel that we are here to help them, in just that 
degree is their confidence in the institution gained, and their 
progress toward recovery furthered, or their condition rendered 
more endurable if, unhappily, they are cases which will require 
homes here for life. 

The motto which has been over the entrance to the men's 
wards of one institution for many years should be the guiding 
principle in our treatment of the insane — " Put Yourself in 
His Place.' ' If you are endowed by nature with that divinely 
human quality, sympathy, you will need no better instructor 
to tell you what to do in each case; but if this quality is deficient 
or dormant in you, you need to be all the more on your guard, 
making up what you lack in spontaneous sympathy by pains- 
taking efforts to observe the Golden Rule in dealing with each 
patient. Most of us are kind at heart, but we are too often 
absorbed in our own affairs and projects, and forget to look at 
things from the point of view of others; we take the fact of a 
patient's coming as a matter of course, and while we are sorry 
for him and mean to do our duty by him, too often we forget 
to show our sympathy in tone and manner as we greet him. 

I am sorry to confess it, but I have seen new patients wel- 
comed (?) in a way that would strike a chill to a normal, healthy 
person, to say nothing of the effect upon a sensitive mental in- 
valid. I have heard the words, "What! You back again!" 
uttered in a most unfeeling tone, when the very fact that the 
person had to return should have entitled her to a warm hand 
clasp and a spontaneous exhibition of sympathy. I have seen 
the new patient eyed askance, or even openly stared at from head 
to foot in a way that made me wonder if the starer possessed a 
particle of womanly feeling. I am inclined to think that the 
sympathy is often really there, though unexpressed, but that a 
certain failure to put one's self in the place of the new patient 
effectually prevents it from coming to the surface, so that one 
sees instead only an expression that seems to say, " Another lot 
of clothes to be looked over and marked !" "Another trouble- 
some person to be cared for ! " Not a vestige of fellow-feeling 
visible in word or expression ! Depend upon it, if you greet a 



36 NURSING THE INSANE [Chap. IV 

new patient this way, the impression you create is far more in- 
delible than the ink you use to mark that patient's belongings. 
Long after your careful efforts in this direction have become 
faded by the sun and by repeated trips to the laundry, the un- 
favorable impression you made on the patient's mind will last. 

Please do not gather that I wish you to be effusive in your 
greeting of the patient. Nothing is more to be shunned than 
the fawning and palaver which an insincere person indulges in 
for the sake of impressing the lookers-on; this is not sympathy, 
it is gush; it deceives no one but the one employing it. What 
I am advocating is a quiet, gentle greeting in a few words, always 
calling the patient by name, a greeting that shows the newcomer 
by look and tone that you want to help her and that, sad as is her 
condition, she has fallen among friends. 

When you ask the new patient to accompany you from the 
office to the wards, call her by name, request that she bid good-by 
to her friends there and come with you. Explain to her that you 
would like to see how much she weighs, help her on and off the 
scales, and if she is feeble, give her your arm to lean on as you go 
to the ward. If she is very weak or feeble, send for male attend- 
ants to carry her, explaining to her, if she is capable of appre- 
ciating the explanation, that you will do so to save her from 
further efforts, since she is tired from her journey. If she is 
resistive, do not pull her, or attempt to force her ; try soothing and 
persuasion first, and only resort to force if all other legitimate 
means fail. Even then, exercise great care not to handle her 
roughly or inconsiderately. 

I wish to urge the necessity for greater accuracy in the taking 
of the height and the weight on admission. These requirements 
are made for scientific purposes; they are valueless unless ac- 
curately taken and accurately recorded. I have not infrequently 
found a discrepancy of six or more inches in the recording of a 
patient's actual height — a discovery that has made me infer 
that the one to whom this duty was intrusted was either in- 
efficient, or, what is worse, negligent, and has attempted to cover 
up the negligence by a rough guess that has fallen wide of the 
mark. Accuracy in taking these conditions must of course be 
supplemented by a painstaking recording of them — the figures 



Chap. IV] THE RECEPTION OF PATIENTS 37 

made so distinctly that no possible misreading can occur in the 
copying. The weight record in every instance should state 
whether the patient was dressed, or only in her night clothes. 
This rule should also be observed in the subsequent monthly 
weight records. Otherwise time and labor are thrown away. 
Not infrequently a patient who, when admitted, is weighed with 
all her clothing on, is then put into the hospital department for 
a month, and, consequently, the next weight is taken in her 
nightgown; by reason of this, a falling off of several pounds 
appears in her weight record, with nothing to indicate that the 
diminution is due to the difference in clothing — the natural 
inference being that the patient has lost weight, whereas in many 
instances there has been an actual gain, but with no means of 
determining it so long as misleading methods are used. 

Accuracy is likewise essential is taking and recording the tem- 
perature, the pulse, and the respiration on admission. And this 
means on admission, it does not mean the day after. It is in- 
excusable to neglect this duty on the ground that there appear 
to be no departures from the normal. As a rule the tempera- 
ture should be taken in the mouth on admission, but wherever 
taken, it should be stated whether in the mouth, the axilla, or 
the rectum. The necessity for this can readily be understood, as 
these duties in a given case devolve upon various nurses from 
time to time, and unless a temperature is taken uniformly, vari- 
ations will show on the chart that are not due to the fluctuations 
of the disease, but to the lack of system on the part of the nurse. 
For absolute accuracy it is necessary that the temperature be 
taken in the rectum. But this is hardly feasible, and as a rule 
not advisable, on admission. After the patient has become more 
accustomed to the life here, however, if for any reason it becomes 
necessary to take the temperature for special investigations, 
rectal temperature should be ascertained, after explaining to 
the patient what you are about to do, and why, and that it can- 
not hurt her in any way. Forestall fears and suspicions by 
explanations, thereby rendering the patient comfortable and 
tractable at the same time. 

In order to insure accuracy, the pulse should be taken a full 
minute, and the process repeated in case any unusual rate is 



38 NURSING THE INSANE [Chap. IV 

noted, or in case the nurse is inexperienced in this procedure. It 
should be stated whether the patient is sitting or lying down at 
the time the pulse is taken. 

The respiration observations also require great care. Calm the 
patient, if possible, and endeavor to observe the speed of the res- 
piration when she is not aware of your doing so. A good method 
is to keep your hand on the wrist, letting her think it is the pulse 
you are interested in, instead of the respiration, as one uncon- 
sciously alters the respiratory rate when one knows it to be under 
observation. If there is great acceleration in the breathing, 
state in your report whether it appears to you to be the result 
of some diseased condition (any chest symptoms, such as cough, 
pain, etc.), or whether of exhaustion, or of excitement, such as 
fright, anxiety, or struggling. 

You are expected, too, to note and report any unusual appear- 
ance of the body — emaciation, obesity, growths, birthmarks, 
injuries, bruises, scars, vermin, bedsores, swellings, wastings, 
eruptions, malformations, dislocations, fractures, sprains, paraly- 
ses, etc. Also impairment of motion of any part of the body, 
or any disturbance of function that you may discover. In short, 
let your inspection of each case be so thorough and accurate that 
your report of it will gratify and surprise the physician as to 
your capability as an observer. Yet all this must be done while 
bathing the patient, done quietly and unostentatiously, so that 
the newcomer is not aware of the scrutiny which you are exer- 
cising. Patients often resent observation by nurses, thinking 
it mere idle curiosity, even when willing to submit later to a 
thorough examination by the physician. Be especially careful 
to avoid wounding the feelings of those who have unsightly 
birthmarks or deformities. They are likely to be morbidly 
sensitive over these things, and you cannot be too considerate of 
their feelings in this particular. You will remember that the 
ward admission blank calls for the condition of the person in 
regard to certain things already enumerated, and in addition, 
the enumeration of the clothing, and the articles found on the 
person. 

Any striking tendencies, as well as the height, weight, pulse, 
temperature, and respiration, may also be recorded on this blank, 



Chap. IV] THE EECEPTION OF PATIENTS 39 

which should be signed and promptly sent to the office of the 
physician in whose service the patient is located. 

In addition to this record, the nurse in charge, or some one 
she details for the purpose, should keep a daily description of the 
patient's behavior for about two weeks after admission, this rec- 
ord to be daily submitted to the attending physician. In this 
account do not merely say that the patient is quiet or noisy, 
idle or active, resistive, destructive, and the like. So far as 
possible, avoid the use of these worn-out terms; be specific by 
telling just how the patient acts and talks, what she does and 
says, and what she expresses; how her emotions show themselves, 
how she spends her time — in other words, give a picture of the 
case so vivid that one reading it can gain a fair idea of the 
actual manifestations you have observed. Thus will your notes 
be valuable adjuncts to the record of the case. 

Many patients arrive at the hospital suffering from the fatigue 
and excitement of a long journey, in addition to the nervous 
strain caused by apprehension at being put in a hospital of this 
character. Some of them, too, have been refusing food for days 
previous to admission, some have been deprived of sleep, some 
are under the influence of drugs or stimulants that have been 
administered just before taking the journey — these and many 
other causes may serve to exhaust the new patient. Your first 
duty after making her feel that she is among friends, though in a 
strange place, is to offer her some simple nourishment — a dainty 
piece of bread and butter, and a glass of water, a cup of hot or 
cold milk, or with old ladies, especially, a cup of tea. These, 
offered graciously and as temptingly as possible, on a small tray, 
with a napkin, will contribute to the bodily needs, at the same 
time that they cheer and refresh the spirit. See that this simple 
refreshment is brought as a surprise to tempt the appetite instead 
of telling the patient beforehand that you are going to get her 
something to eat. 

As a rule it is well, instead of immediately ushering a patient 
into the sitting-room of the ward, to be stared at by the assembled 
groups, or into the hospital department where the sights un- 
usual to her would distract and perhaps terrify her, to usher 
her quietly into a room by herself — your own room would be as 



40 NURSING THE INSANE [Chap. IV 

free from interruption as any — and there, while removing her 
wraps and reassuring her as to the people and the surroundings, 
let her gradually grow accustomed to you and to the strange life 
upon which she is entering. In this room the nourishment can 
best be administered, and here, as a rule, the bodily condition 
taken. 

The nourishment being attended to, the condition of the pulse, 
temperature, and respiration taken, immediately recorded (and 
promptly reported to the physician, if it is very abnormal), your 
next duty is to administer the bath. And here I must urge the 
utmost care and delicacy. Exhausted patients should be given 
a sponge bath while lying in bed, protected by screens from un- 
necessary exposure — not only that, but protected as far as pos- 
sible from exposure of any part except the one being bathed at 
the time. 

Patients whose condition warrants it should be given a warm 
tub bath, finishing off with a gentle lukewarm shower bath, care 
being taken to explain in every case what is to be done, so as not 
to give a shock to the nervous system. 

You need to bear in mind that many patients received here have 
never been in a bath tub, much less under a spray, and be con- 
siderate of their natural apprehension concerning these things. 
Do not scorn, ridicule, or slight their fears, but try to appreciate 
and to allay them. Explain to each patient that the rules require 
that every one be given a bath on admission. Some may urge 
that they had one that very day. Tactfully make clear to them 
that the bath will rest and refresh them by removing the dust of 
travel, and by its soothing effect will help them to sleep better. 
Other patients will tell you that they don't believe in baths; 
do not treat this statement with ridicule or contempt, but in your 
most ingratiating manner set forth the delights of a bath and 
how much better they will feel afterward. You will by so doing 
make them willing converts instead of rebellious subjects. The 
impression that this first bath makes on them will often deter- 
mine their attitude toward subsequent ones; a little extra pains 
at this time on your part will be time well spent, even if there were 
no higher motive considered than your own ease in the future. 
A shampoo should also as a rule be given with this first bath, 



Chap. IV] THE KECEPTION OF PATIENTS 41 

and while I cannot here go into the details to be observed in the 
bathing of patients, I want to caution you, when washing the 
head, hair, and face, always to be on your guard that no soap- 
suds trickle down from the hair to the eyes. I have seen patients 
with bloodshot eyes the morning after admission, and have 
heard their just complaints of a careless attendant who allowed 
this to happen. It is often inattention to some such thing that 
makes a patient dread the bath — as the burnt child dreads the 
fire. I believe in the majority of cases, if the nurses are pains- 
taking enough, they can so administer the first bath that the 
patients will submit willingly in the future. 

All patients* heads, bodies, and clothing should be carefully 
examined for vermin on admission, but this can usually be done 
in such a way that the patient does not know what is being done. 

Above all things, be as careful of your patient's feelings in 
administering her bath as you would wish others to be of yours 
under similar circumstances. Think at the start what violence 
is done to a woman's modesty in submitting to being bathed 
by another if she has not been accustomed to it; many women 
come here whose bodies have not since childhood been exposed 
to the sight of a fellow-being. Remember this, and respect the 
natural shrinking from exposure that every modest woman feels 
at having to undergo such a trial. Let your own delicacy teach 
you how to refrain from giving offense, and how to make the 
ordeal as easy as possible for your patients. Remember that an 
insane person has not of necessity lost her modesty. Permit no 
more nurses in the room than are necessary for safety in a given 
case. Your daily work in this line makes you accept as a matter 
of course what is to the patient a real trial. Never allow your- 
selves to get hardened in this particular. 

In cases where the patient is irrational and violent it is dif- 
ferent. Explanations are then as a rule useless, and you may 
need the help of three or more nurses, but always be as gentle, 
patient, and conciliatory as possible. Even the most irrational 
patients receive and retain vivid impressions of the treatment 
received on admission, when to all appearance they were oblivious 
of what was happening. Their acute and graphic comments on 
recovery concerning the reception given them are often deplor- 



42 NURSING THE INSANE [Chap. IV 

able evidences of the carelessness or the unfeelingness of the 
attendant from whom they should have received sympathetic 
treatment. 

Remember, too, that if a patient is so far alienated from the 
normal that she has lost her native modesty, it is your duty to 
seek to restore her sense of it by taking extra pains to act as 
though you thought she still possessed it. A good rule to ob- 
serve in all your dealings with the insane is this : Treat a patient 
as though you believed her to be what she really ought to be. 
By so doing you reform her as far as possible. 

A patient's clothing and belongings on admission should be 
searched for concealed weapons, matches, medicines, money, or 
other valuables, the same promptly turned over to the super- 
visor and recorded on the blanks furnished for the purpose. 

Another important thing to be observed soon after the patient 
is admitted is a careful explanation to her of the principal rules 
and customs of the institution. If you can make patients under- 
stand that the various things required of them are because of 
established rules which have been found necessary in the main, 
and not because of your own arbitrary dictation, they will con- 
form much more willingly, and will not be as likely to chafe 
under the requirements as they will if they think you tell them 
to do this or that, to go here or there, merely because you say so. 

Tell them what the custom is in regard to the marking and list- 
ing of clothing and belongings, explain that this of necessity 
takes time, that meanwhile they will need to put on some clothing 
provided for such occasions; that any valuables in their pos- 
session, and their money, will be placed in the safe in the steward's 
office, and that their money can be had on application to the 
supervisor as needed. Let them understand that they have in 
the supervisor a friend who will look after the prompt delivery 
of their belongings, who will investigate any failure of these 
things to return from the laundry, and who will make requisi- 
tions for their needs in the way of new clothing and the like, 
whenever these needs arise. All these and other rules, so well 
known to you, necessitate careful explanation to each new case. 
Such explanations at the start will often obviate the not un- 
natural belief that they are being maltreated, defrauded, robbed. 



Chap. IV] THE KECEPTION OF PATIENTS 43 

Let me repeat, allay fears and suspicions that already exist, 
but guard against their arising, if possible, by painstaking, 
kindly explanations. Treat patients like reasonable beings, en- 
titled to elucidation concerning the strange conditions they are 
entering upon. They are more susceptible to reason than you 
sometimes give them credit for being. The cases are compara- 
tively few in which a nurse's honest endeavors to explain these 
matters under discussion will not be appreciated and, in part at 
least, understood. Even if the patient does not always compre- 
hend fully, she is likely to gather that you are friendly and con- 
ciliatory, and this is much better than to have her gather that she 
is a helpless being in your power, forced to do this and that like 
a dumb beast at the mercy of your dictation, simply because she 
has been committed as insane. 

Tell the new patient the hours for meals, show her where the 
dining room is, and the location of other places on the hall — the 
sitting room, the drinking water, the water section. If she is 
to sleep in a room with another patient, forestall any fears she 
may have as to that patient by seeking to put the roommates on 
friendly terms; tell her, if she is to room on the hall, that a night 
nurse will make the rounds once an hour and that she can ask 
for anything she needs at such times. If she is put in a hospital 
department, it will go far toward reconciling her to being in a 
room with so many others if you explain that until we are familiar 
with her needs, we will give her a bed in the large room with other 
patients, where she can have the services of nurses at all times of 
day and night. Never lose sight of the natural apprehension 
that any one would feel at being locked in for the first time on the 
wards of an institution of this kind, and spare no pains to quiet 
such fears. 

Attention to the bowels and bladder of all new cases is 
very important. Report conditions of impaction and distension 
immediately. Patients who are excited or exhausted or in a 
stupor need especial care to guard against an over-distended 
bladder. A specimen of the twenty-four hours' amount of urine 
should be sent to the laboratory as soon as possible, accompanied 
by the patient's name and ward location, the date, and a state- 
ment as to the total amount voided in twenty-four hours. 



44 NUESING THE INSANE [Chap. IV 

New patients are not to be set to work, nor taken out for ex- 
ercise, nor to chapel, until the attending physician has consented 
to it. Do not, however, neglect to call the doctor's attention to 
these matters if he forgets to speak of it after a few days, espe- 
cially in persons whose bodily condition appears to admit of 
these recreations. 

The rules concerning letter writing, postage, correspondence 
with relatives, and concerning the receiving of visitors, should 
be made clear to new arrivals at an early date. Let every patient 
feel that in the event of not having stationery of her own, she 
can, when she wishes to write to her relatives, have some which 
is provided for just such purposes, and that in the absence of 
pin money for postage, a stamp will be placed upon her letter in 
the office. Patients who can afford to supply themselves with 
these conveniences should be encouraged to make known their 
needs in letters to their friends, but those who cannot afford this 
should never be made to feel that a reasonable amount of station- 
ery is withheld or given grudgingly. All persons whose mental 
and physical condition admits of it should be encouraged to 
write to some relative once in two or three weeks, at least, in 
order to keep alive a healthy interest in home life and in the world 
at large. Some patients will, of course, wish to write as often as 
once a week, and some need to be restrained from daily letters, but 
such cases should be reported to the physician whose duty it is to 
regulate these matters. On no account is a letter written by 
a patient to be withheld or destroyed by the nurse, however 
illegible or irrational it may be. Indolent and indifferent pa- 
tients need frequent reminders to write to their friends. 

Tact is requisite in explaining the necessity for leaving out- 
going letters unsealed that they may be examined in the office, 
if necessary, by the physician. But it should also be stated that 
their letters from their friends may come to them unopened. 
A patient capable of writing letters can, as a rule, be made to see 
the necessity for leaving outgoing letters unsealed, distasteful 
as it may be to do so. A sensitive person naturally writes under 
constraint when knowing that the writing may fall under the eyes 
of another than the one to whom the letter is addressed, even 
though no secrecy is contained therein. While this is unavoid- 



Chap. IV] THE RECEPTION OF PATIENTS 45 

able to a certain extent, patients should be made to feel that only 
the doctor in charge has the right to read the letters they write, 
and that he will see to their being sealed and sent as soon as they 
are examined, if found suitable for sending through the mails. 
The patient has the right, and it should be clearly made known 
to her by the supervisor that she has this right, to put her letters 
directly into the hands of the supervisor, whose duty it is to con- 
vey them promptly and inviolate to the physician. A nurse who 
interferes, or reads a communication of a patient, unless urged 
to do so by the patient, is guilty of a grave misdemeanor. It 
ought not to be necessary to mention this fact, and I would not, 
were it not that prying nurses have from time to time made a 
point of reading patients' letters, and unprincipled ones have 
even transgressed their rights to the extent of intimidating the 
patients if they wrote certain facts to their friends; still others 
have so influenced patients as to inspire them to send out fawning 
and high-colored eulogies of the nurses in question. Such con- 
duct is inexcusable and unscrupulous, and is, of course, beneath 
the practice of any high-minded person. 

There are cases, it may be stated, where the patients can only 
be induced to write letters under the encouraging supervision 
of the nurse, and many a patient's friend has been cheered by a 
letter which cost the nurse literally hours of coaxing and per- 
suasion before its completion could be effected. Such instances, 
it is hardly necessary to say, do not come under the criticism I 
have just made. But even in these cases, do not tell the patient 
what to write. Suggest, if he actually needs suggestion, that he 
tell about the place, his room and surroundings generally, the 
entertainments he has attended, and the like, but do not try in 
the remotest way to keep him from telling anything that he wants 
to tell of what impression the place makes upon him, or of what 
treatment he has received here. Let your concern be to keep 
the treatment such, so far as you and the nurses under you are 
concerned, that you will have no reason to fear the truth, and if 
he distorts the truth, or tells absolute falsehoods, you still have 
nothing to fear, for if you are innocent, you will welcome any 
investigations that may be made concerning these accusations. 
If you see that he has used obscenity or profanity in his letter, 



46 NURSING THE INSANE [Chap. IV 

you may tell him that the doctors will be unable to send such 
a letter through the mail, but if he does not willingly erase It, 
turn the letter over as usual to the proper authorities. If you 
learn that a patient has written to his friends that such and such 
a patient is here, giving name and residence of a given patient, 
try to persuade him that it would be kinder to refrain from men- 
tioning such fact, on the ground that he would not like to 
have the news of his being here circulated among his friends, 
and consequently should forbear spreading news in regard to 
others. 

So long as the opinion obtains among people at large that mental 
diseases carry with them a certain stigma, just so long will people 
be sensitive about being cared for in hospitals for the insane, 
and while nurses should do all that they can, directly and indi- 
rectly, to lead people to a more enlightened view of insanity as a 
disease, not a disgrace, still they are in duty bound to respect the 
natural reluctance patients and their friends have toward spread- 
ing the knowledge that a given person has been or is thus afflicted. 

The patient's name and the ward on which he is located should 
be placed on the inside of the lapel of each outgoing letter. 
As a matter of fact, many a letter written by patients who the 
physician knows can be trusted not to resort to connivance, or 
obscenity, or profanity, is permitted to go to the friends without 
examination in the office ; but unless exceptions are made by the 
physician in a given case, all letters should be sent to the office 
unsealed. 

I wish to remind you of the extreme care necessary in dealing 
with violent and resistive cases. When force is necessary, let 
it be quietly and firmly administered, by marshaling sufficient 
help so that the struggling patient sees the uselessness of further 
resistance. But let the nurse first control herself if she would 
control her patient — control voice, hands, manner. Do not 
scream at, scold, threaten, or ridicule a patient, whatever the 
provocation. On no account threaten a patient with seclusion, 
or with the safety sheet, or with a bath. It is a nurse's fault, 
and a grave one, if the patient ever gets the notion that baths or 
packs are administered as a means of punishment. Nor should 
the slightest appearance of " discipline" ever enter into the 



Chap. IV] THE RECEPTION OF PATIENTS 47 

administration of a bath of any kind, or the application of a 
safety sheet, or a pack, or seclusion. Patients should be made to 
understand that restraining measures are of necessity adopted 
on occasion because they are unable to control themselves — 
that we do it reluctantly, and only for the purpose of protect- 
ing them, or others, or to prevent wanton destruction of prop- 
erty, etc. 

Preserve the patient's self-respect by treating him as a rational 
human being when he is in the faintest degree capable of rea- 
soning. When incapable, treat him kindly, considerately, as a 
patient mother would treat a wayward child, not as a rough 
uncultured person would order about a dumb animal, or a stupid 
servant. It is only a narrow-minded and an ill-bred person that 
will exercise petty authority over helpless beings intrusted to his 
care. A refined nature will show by sympathy, by kind glances, 
and by forbearance with trying peculiarities and whims, that the 
wish and the intention are always to aid troublesome charges — 
to improve them, to guide, but never to "boss " them. 

Never command or coerce when you can persuade. When 
coercion is imperative, do not let temper or resentment enter 
into word or manner; and, whenever practicable, explain to 
the patient that it is with extreme reluctance that you force 
him to do a given thing, that it is only because you must carry 
out the doctor's order; and tell him that you much prefer 
that he do it voluntarily. This will result in many instances in 
the patient's yielding, though reluctantly, rather than submit to 
force. The mildest power is indeed the most potent, and a tact- 
ful request more efficacious than a rude or brutal command. 

Take pains to introduce the new patient by name to the other 
nurses, to each doctor as he visits the ward, and to some of the 
more congenial patients around him. Use the titles, Mr., Mrs., 
or Miss, before names, or, if the patient is very young, he may 
be called by his given name. On no account are women patients 
to be spoken of by their last names among the nurses, and no 
nicknames are to be used. 

In a few instances, where a patient's delusional state is such 
that he makes homicidal attempts on one who addresses him by 
his real name, we find it wise to make exceptions and cater to 



48 NURSING THE INSANE [Chap. IV 

the whim, avoiding the use of the name that gives rise to such 
dangerous exhibitions of temper. Such exceptions are, however, 
to be decided by the physicians. 

As already urged, respect each patient's individuality, let him 
feel that he is a factor in the life of the ward, that he counts for 
something, that he is not lost or swallowed up in that heteroge- 
neous mass, " the patients," but that, so far as lies in your power, 
his comfort shall be considered, his interests made your interests, 
and his progress toward recovery aided. Courtesy begets cour- 
tesy. Make your patients feel that we are not lost to all social 
observances simply because we live in a hospital for the insane. 

There are those of you who would not think of neglecting the 
proper ventilation of the ward, the nickel trimmings of your 
water faucets, the polishing of your floors, the immaculate order 
of your clothes rooms, the bathing of your patients, or the atten- 
tion to any of their temporal wants — such neglect would be 
inexcusable in your eyes, whether in yourselves or others. Are 
you just as careful to minister to the delicate sensibilities of these 
nervous and mental invalids ? Do you always try to maintain a 
cheery, tranquil moral atmosphere on the wards, and are you on 
the lookout to let fall the kindly glance and soothing word that 
may brighten the despondent souls and warm the lonely hearts 
of patients in your care ? 

Let your faithfulness extend to these things also, if you would 
truly minister to their diseased minds. 






CHAPTER V 

WARD MANAGEMENT AND DUTIES OF CHARGE NURSE 

The general management of the ward devolves upon the nurse 
in charge, who should, of course, be carefully trained and self- 
disciplined. It is she who is responsible for the order and sys- 
tem, or the disorder and lack of system, that there prevail. 

" To be in charge," as Florence Nightingale well said, "is not 
only to carry out the proper measures yourself, but to see that 
every one else does so too; to see that no one either willfully or 
ignorantly thwarts or prevents such measures. It is neither to 
do everything yourself, nor to appoint a number of people to each 
duty, but to insure that each one does that duty to which he is 
appointed." 

This organized system of each nurse's regular attendance to 
her own duties is what constitutes a well-managed ward. A head 
nurse may be ever so faithful in doing the work she assigns her- 
self to do, but unless she also sees to it that her assistants do 
theirs equally well, she is derelict in duty, and only half fulfills the 
responsibilities of her position. Any failure to perform duties 
properly, any carelessness or inefficiency on the part of her assist- 
ants, is something that the nurse in charge is directly responsible 
for, unless, failing in bringing about desired results, she promptly 
reports the delinquent to the supervisor, who should, in turn, as 
promptly report to the visiting physician. It is inexcusable in a 
charge nurse, on her attention being called to the negligence or 
inefficiency of an assistant, to offer the excuse, "Yes, I know, but 
I can't do everything." It is not expected that she do everything 
— that is just the point; but it is expected that her ward work 
shall be so systematized that each nurse and attendant knows 
definitely what is required of her, and failure to do this should 
be ascertained by the one whose duty it is to hold each assistant 

e 49 



50 NURSING THE INSANE [Chap. V 

to the fulfillment of her prescribed tasks. She should never do 
the work assigned to an assistant except in case of emergency. 
To do that is to destroy her discipline and render a careless 
attendant more careless. 

The nurse in charge is there to exercise a wise guidance and 
supervision of the ward at all times, and not only that, but to have 
such order and system prevail, by reason of her attention, train- 
ing, and instruction, that affairs will be properly conducted even 
in her absence. One occasionally sees a charge nurse so vain 
that she wants to be missed, she seems almost pleased if things go 
at "sixes and sevens " in her absence, thinking that her qualities 
will shine the brighter in comparison. This is a palpable fallacy. 
A ward that is well managed — one in which each nurse does her 
work from a sense of duty, regularly and faithfully, one in which 
the nurse in charge is such a power for good that her own quali- 
ties are caught and imitated by her subordinates — is the ward 
that will run smoothly even in the absence of the charge nurse. 
Written directions concerning special matters and special cases 
should be left by the nurse in charge in her absence from duty. 

A spirit of friendliness, a cheery atmosphere, a feeling of unity 
and helpfulness, these are the things the charge nurse must seek 
to have prevail in the department over which she has sway. 
If she has force of character and the executive ability requisite 
for the proper fulfillment of her position, what she is, or what she 
is not, is felt in the general atmosphere of the ward. If she is 
tidy in dress, prompt in coming on duty, exacting in seeing that 
her assistants do the same, if she is courteous to her associate 
nurses, respectful to the matron and supervisor, and loyal to the 
physicians, gentle and thoughtful in her care of the patients, 
considerate of the patients' friends, and earnest and diligent in 
seeing that the physicians' instructions are carried out with 
promptness and fidelity, these things are imitated by her subor- 
dinates. What she is, is reflected in the conduct of the other 
nurses who come under her influence. On the other hand, if she 
possess just the opposite of these qualities, her influence is as 
potent for bad as that of the efficient nurse is for good; if she 
is an eye-servant only, her associate nurses will to a great 
degree become eye-servants also, except in some rare instances 



Chap. V] WARD MANAGEMENT 51 

where conscientiousness and principle are strong enough to 
prevail even when a poor example is set by one to whom subor- 
dinate nurses naturally look for inspiration and guidance. 

I like to have a charge nurse consider her relation to her 
patients something as does a hostess hers to her guests, especially 
in the hours of comparative leisure when she is on duty, but with 
no actual work demanding her attention. At such times let her 
mingle with her patients as among her guests, gracious in manner 
and thoughtful for the comfort of each one, especially the ones 
that are timid and retiring. Let me remind you, though, that 
when I say gracious I do not mean patronizing. Let her bring 
together those who will be congenial, draw out those whose talents 
for music, reading, dancing, or recitation would contribute to 
the pleasure of the company, arrange a quiet game of cards here, 
perhaps a bean-bag contest somewhere else, and in various ways 
put her wits to work to interest and amuse her charges. Let the 
early evening hours be given over to some recreation; plan for 
these things so that the patients will look forward to the evenings 
and will bestir themselves in turn to do what they can to con- 
tribute to the entertainment. Do not be afraid of music and a 
little good-natured noise and jollity in the parlors in the evening. 
A little nonsense, hearty laughter, and a cheerful social time will 
make all of you sleep the better, and start out the succeeding 
day in better spirits and with a community of interest that will 
surely be developed by working and playing harmoniously to- 
gether. 

It is a good plan for the nurses on each ward to organize them- 
selves into a committee of amusement, letting each one be re- 
sponsible for the amusement of a certain evening. In this way 
personal interest is stimulated, responsibility is shared, variety 
is secured, and a wholesome rivalry as to who shall conduct the 
most successful evenings is established. Sometimes very simple 
preparations will yield the pleasantest results. 

In connection with music on the wards, discretion must be 
used; there should be temperance in all things, even in music. 
While it is desirable not to interfere with a patient's liberty in 
any legitimate amusement any more than is necessary, you will 
sometimes have to consider the good of the many, even to the 



52 NURSING THE INSANE [Chap. V 

restriction of one person's liberty. Occasionally a patient, unless 
hindered, will sit at a piano and play and sing, for example, 
Gospel Hymns from beginning to end, for hours at a time. Per- 
haps that one patient enjoys such a feat immensely, but you 
must consider its effect upon the other patients. There are vari- 
ous ways of obviating the annoyance besides locking the piano 
and arbitrarily prohibiting playing and singing. No nurse has a 
right to do that ; in fact, no one but the physicians may dictate to 
this extent. If music is objectionable to a nurse, if she has a 
headache, or is irritated by the efforts of the patients to entertain 
themselves, and she alone, by reason of her idiosyncrasies is 
annoyed by it, she should seek the aid of medicines for her head- 
ache, if she has one, or perhaps take that opportunity to walk 
out if the music is merely distasteful to her, or she should " grin 
and bear it," remembering that the pianos are on the wards for 
the use of the patients. A tactful nurse will know how to sup- 
press the persistent performance of monotonous music by sug- 
gesting that she would like to hear this or that — something of 
an entirely different nature — or she can sometimes engage the 
patient in conversation, and so let the piano and the enforced 
listeners rest, often without the assiduous musician realizing 
that she is being managed. 

In connection with her duties as hostess of the ward over which 
she presides, the charge nurse will of course receive all visitors 
standing, greeting them courteously, and showing herself ready 
to do the honors of the ward, whether these visitors be strangers, 
physicians, matron, supervisor, or nurses from other wards. 
And she will so instruct all new assistants at the beginning of their 
work in her domain that they will readily grow into the spirit of 
courtesy. If a new attendant is so ignorant of the fitness of 
things that she remains sitting when a visitor enters the ward, 
it is a reflection upon the nurse in charge if this breach of eti- 
quette is not corrected soon. Sitting around on radiators and 
tables is not to be permitted. Attendants prone to such customs 
must be promptly made k to understand the impropriety of such 
behavior. 

Especial care is needed in precept and example on the part of 
the charge nurse and the senior assistants, in making new attend- 






Chap. V] WARD MANAGEMENT 53 

ants familiar with the necessary rules and traditions of the 
hospital, and in starting them out right, with a proper attitude 
toward the work. The new helpers, having so much to learn at 
once, cannot be expected to remember all that is told them with 
one telling. Furthermore, they are sometimes transferred from 
one ward to another so rapidly that no regular and continuous 
instruction is afforded them. Accordingly, it is better in re- 
ceiving a helper to your ward, unless she has been in the institu- 
tion for some time, to proceed on the same plan that you would 
with a new attendant, taking care to use tact in your methods of 
instruction, asking her if she has been told this and that, and so 
outlining the essential points of instruction without making her 
feel that the instruction on other wards, or her grasp of it, has 
been defective. 

Charge nurses should take care to make probationers feel 
welcome. Too often they are made to feel that it is a trial to 
receive them for instruction. It does entail extra work, extra 
responsibility, for all the details of nursing that have become 
so familiar to trained assistants have to be patiently and fre- 
quently explained to the uninitiated. The charge nurse needs 
to remember that there was a time when she herself was inex- 
perienced and unskilled, perhaps as awkward as the pupil nurse 
she is now called upon to instruct. It should be her pride and 
pleasure to see all of her helpers grow in deftness, skill, and 
efficiency under her tutelage. Of course it is far easier to do 
difficult things than it is to stand by and laboriously teach pupil 
nurses to do them ; but if she deals justly with her nurses, she 
will see that they have the opportunities and the guidance 
necessary to acquire ease and skill in the practical points of 
nursing, and these can only come from doing them, never from 
merely standing by and seeing them done. 

In order that the entire institution may work in harmony, 
there must of course be uniformity of system, cooperation be- 
tween the heads of departments, loyalty to superiors, helpfulness 
to and consideration for all. 

The charge nurse when on duty is expected to accompany the 
attending physician on his rounds, taking pains to acquaint 
him fully with the condition of the sick patients, with reports 



64 NURSING THE INSANE [Chap. V 

of new cases, and of happenings of import since his last visit. 
She should make it a point to be on hand at these times, and 
it is a good plan for her to keep a small memorandum of things 
necessary to report, thus making it impossible to offer the excuse 
for neglect to report important things that one sometimes 

hears — " It slipped my mind because was so noisy," or 

because such and such a thing happened. It is her duty not 
to forget, and the habit of keeping a memorandum will aid her 
in this duty. 

She should take down the special directions given by the 
physician, not trusting to her memory to recall the various 
things that may arise in the course of the rounds. The list 
of medicines and the charts, the weight lists, etc., should be at 
hand for ready reference when the physician is visiting the ward, 
and there should be kept lists and instructions of patients having 
regular baths, douches, and special treatment, with the tempera- 
tures and other details outlined, the days and hours for treat- 
ment, etc., so that in the absence of the charge nurse, the 
affairs of the ward may go on uninterruptedly. 

Some of the requisites for an efficient charge nurse, in addi- 
tion to executive ability, good breeding, an equable temper, 
and conscientious and painstaking attention to duty, are the 
following: She must be a good and economical housekeeper, 
looking after the State's property and her patients' belongings 
as carefully as she would after her own. Economy in the use of 
heat, lights, water, food, and ward supplies in general is an in- 
dispensable quality in a charge nurse. She will check useless 
waste as rigorously as though she were paying for it herself. 
The State puts this trust in her. Her own self-respect demands 
careful supervision in these matters. 

She should keep a neat, accurate, and up-to-date inventory 
of all the ward furniture, should see that the ward supplies are 
kept up, that the linen is in good order, that the medicines are 
kept carefully locked, and faithfully administered according to 
directions; that the temperatures, pulses, and respirations are 
carefully taken and accurately recorded, and likewise the weigh- 
ing of patients. The proper ventilation of the ward, the main- 
tenance of the required temperature, and the general hygiene 



Chap. V] WARD MANAGEMENT 55 

of her department are matters she is directly responsible for. 
It is especially incumbent upon her that she train her assistant 
nurses in the careful observation and recording of symptoms, 
in the giving of enemata, in catheterization, douches, and baths, 
and in the dressing of wounds and the nursing of special cases. 
The special diet of patients must also receive her intelligent 
supervision, and any great variation in weight in a given case, 
whether it be a loss or gain, should be mentioned to the physician 
in charge. Also any injury, or assault, or bed sore, or accident, 
or menstrual disorder, or other complaint or appearance of 
illness, should be promptly reported to the visiting medical 
officer, however slight it may seem, and anything of moment 
should be immediately reported to the office, not waiting for 
the official visit to take place. So far as possible, nurses in 
charge should take pains to report happenings or changes on 
their wards to the physician in immediate charge of that ward, 
but on failure to find the ward physician, important occurrences 
should be reported to some other medical officer, while matters 
of grave and critical moment should be reported to the first 
physician accessible. On the next visit of the regular visiting 
physician to the ward, mention should be made to him of im- 
portant changes which have been temporarily reported to another, 
even if they have already been attended to in his absence. 

The charge nurse must make her assistants feel the importance 
of her being apprised of all that happens on her ward. No 
matter is too trivial for her attention. If she has the requisite 
dignity and tact to make her a success in the position, she can 
do this without evincing a domineering spirit or arousing the 
antagonism of subordinate nurses. Sympathy, consideration, 
and dignity are indispensable qualities in dealing with assistants. 
While being friendly and helpful, she must never be familiar 
with nurses or patients. She must let the nurses feel that they 
have in her a ready instructor, but one who will suffer no breach 
of discipline and no slighting of duty. She will let them see 
by her trained observation of generalities and of details that it 
is difficult to escape her watchful eye. By her own attention to 
systematic work and to tireless observation of all that makes 
for order and harmony, she will inculcate order and harmony 



56 NURSING THE INSANE [Chap. V 

in her assistants. She must teach them in season and out of 
season the necessity of having a place for things and putting 
them in their respective places, not occasionally, but invariably 
— a practice that, however troublesome it may seem, is always 
easier in the end, although it entails considerable self -discipline 
and patience to bring it about. 

The charge nurse needs a large supply of tact and charity. 
She is in a position where she is frequently forced to correct 
and rebuke her assistants. To be able to administer a reproof 
without arousing antagonism and yet have it effectual is often 
a delicate task; nevertheless it can be done so that the one 
meriting the criticism will have only respect for the one who 
gives it. The spirit and the manner in which criticisms are given 
largely determine the way in which they are received. 

All gossiping on the ward is out of place, and the nurse in 
charge who has a proper appreciation of her duty will neither 
lower herself by such indulgence, nor permit such conduct on 
the part of her assistants. Especially to be avoided is the pro- 
pensity that attendants often show to chatting together in the 
morning when coming on duty, perhaps harmless gossip in 
itself about things that have happened to them the night before, 
or their last time off duty, but entirely out of place here, and 
not to be permitted on the ward, where their time and attention 
are required for the duties at hand. 

The head nurse will permit no calling down or up dumb 
waiters to anybody, except the necessary instructions to the 
waiter boys; she will permit no undue familiarity between pa- 
tients and nurses, and no loud or unseemly talk or behavior on 
the part of the nurses under her supervision. She will be held 
responsible for her nurses and attendants being in the prescribed 
uniform at all times when on duty. 

The head nurse is directly responsible for the proper admission 
to and discharge of patients from her ward, and for their transfer 
to other wards, and will not only give these matters her personal 
attention, but will also see in the case of transfers that the nurse 
in charge of the ward to which the patient goes is informed of 
all that is necessary to an intelligent understanding of the case. 

She will exercise a special supervision over parole patients, 



Chap. V] WAKD MANAGEMENT 67 

being on the lookout for indications of oncoming periods of excite- 
ment or of depression that would make a withdrawal of their 
parole advisable. 

The needs of patients concerning clothing and accessories to 
their toilet should receive the care of the nurse in charge. That 
they receive their mail promptly, and that outgoing letters are 
promptly sent to the physician's office, should be a matter of her 
conscientious attention. The recording of the dates and names 
of visitors, and their relationship to the patient should be sys- 
tematically attended to, and any conspicuous or interesting 
feature of the visit, or any marked effect upon the patient, 
favorable or unfavorable, should be reported to the visiting 
physician. 

All attendants who give promise of developing into good 
nurses should be encouraged to enter the Training School, and 
all who do enter should be held to the regular attendance upon 
lectures, and stimulated to maintain a lively interest both in 
the lectures and in the practical training on the wards, in the 
daily attention to the numerous details of their work. 

New attendants should be carefully drilled in the use of the 
ward telephones and in the rules governing the same. They 
should be taught especially how to ring up and ring off, how to 
make their requests or to deliver their messages in a calm, clear 
tone, how to respond to calls, and how to reply to an order given 
over the 'phone, as a rule repeating any important order, to 
insure perfect understanding of it, and making sure that the one 
giving the order, or calling them up, has finished what he wished 
to say and dismissed them before they hang up the receiver. 
No visiting or gossip or unnecessary talk is to be permitted over 
the telephone. 

The head nurse is responsible for the proper transmission to 
night nurses of special instructions concerning new patients, 
or concerning any special thing, and should require of the night 
nurse a personal account of any unusual happenings in her de- 
partment during the night. 

Nurses in charge of hospital departments should see that the 
supplies in the dressing basket are renewed when needed. This 
basket should contain absorbent cotton, lint, gauze, roller band- 



58 NUKSING THE INSANE [Chap. V 

ages of cotton and gauze of various widths, adhesive plaster, 
scissors, safety pins (large, small, and medium), common pins, 
needles, white thread, and a thimble and a tape-measure. 

While order and system are indispensable in the ward manage- 
ment and in the instruction of assistant nurses, it is especially 
desirable that unnecessary routine be avoided in dealing with 
patients. A perfunctory compliance with one's duty is deaden- 
ing to any alert interest. You must try to get a fresh eye 
frequently, so that you see in each case a fresh possibility for 
improvement and encouragement. 

Watch for chances to arrest the patient's attention and in- 
terest; one thing works in one case, another in another; lead him 
out of self-absorption by offering a new interest in something, 
or a new aspect of an old interest. Sometimes a mere trifle 
works wonders in starting a patient on the road to recovery. 

Above all, keep your able-bodied patients occupied at some- 
thing a goodly portion of each day. A nurse should be ashamed 
to see or to have seen on her wards a lot of listless, unemployed 
patients. Much is lacking in her endeavors if this is a customary 
sight. 

Let your patients feel that as charge nurse your greatest pleas- 
ure is in giving them pleasure. Be sincere in this. If you are, 
your patients will feel it, and your influence over them for good 
will be tenfold greater than it otherwise could be. The awaken- 
ing of a helpful concern in the life about them, the inculcation of 
tidiness and of ambition, the direction of employment and of 
recreation, interest on your part in their reading, in their friends, 
and in their letters from home, the cultivation of friendly inter- 
course among themselves, and among the other nurses, the stimu- 
lation of interest in outdoor life, all these things have an impor- 
tant bearing on the mental and moral welfare of your patients. 

Encourage them to tell you about the books they are reading, 
about the sermon they have heard, about what they saw out of 
doors, and about what they themselves feel would contribute 
to their well-being and recovery. Their ideas, even though lamely 
expressed, will be suggestive to you, and the expression of them, 
and your interest in it, will be helpful to them. Cultivate any 
special gifts or tastes that patients may have, and make them 



Chap. V] WAED MANAGEMENT 59 

feel that in this cultivation they are contributing to the enjoy- 
ment and well-being of others. 

See that your assistant nurses are always mindful of their 
patients' pleasure at entertainments and dances and during their 
daily walks, and that the dining-room attendants are especially 
watchful of their needs at meals. 

These duties of the head nurse, as outlined, are arduous in the 
extreme. Even on the best-managed wards, and with the best- 
trained assistants, trying and harassing occurrences and ex- 
periences will be met, and the head nurse, with so many things 
for which she is held responsible, will never find her work easy. 
Vigilance and equanimity, infinite tact and patience, are in 
constant requisition, but with an intelligent understanding of 
her duties, and the executive ability without which she cannot 
hope to succeed, the conscientious and humane nurse will find 
abundant reward for the faithful discharge of these manifold 
duties. 



CHAPTER VI 

HYGIENE OF THE WARDS AND OF HOSPITAL DEPARTMENTS 

The ward, or hall, with its sitting room and adjoining rooms 
arranged for one, two, or more occupants, should be considered 
as the home of the patients; the hospital departments, or in- 
firmaries, should be regarded as sick rooms. Bearing this 
distinction in mind, the management of hall and hospital ought 
to be easily outlined, and, with order and system prevailing, 
effectively executed. 

Let us then consider the management of the ward as regards 
ventilation, cleanliness, order, and attractiveness, since no place 
can be truly homelike unless these conditions prevail. 

What do we mean by ventilation? We mean to supply 
fresh air and to remove foul air. Why is it necessary to supply 
fresh air and to remove foul air? Because air that has once 
been breathed has been deprived of its building-up qualities and 
is therefore unfit to be breathed again. We would not think 
of bathing in water which had already been used for that pur- 
pose, because the dust and the worn-out particles that accumulate 
on the body pass into the water — the very thought of this is 
repugnant to us, yet many persons think nothing of breathing 
over and over again, not only the air they themselves have already 
breathed and so contaminated, but they also breathe over and 
over the air that has been vitiated by the breaths and the emana- 
tions from other persons as well. When we think. of it, how 
much more fastidious we ought to be concerning the purity of 
the air we take into the lungs than concerning the water which 
touches the skin, for the contact of the air is so much more in- 
timate, becomes so much more a part of us than does mere 
surface contamination. When we insult our lungs by giving 
them impure air to breathe, we are starting a process that is 

60 



Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 61 

far-reaching; the blood that is sent to the lungs to be purified 
is only partly purified — washed in soiled water, as it were 
— and goes back to the cells of the various tissues with not 
enough of the up-building qualities to feed and renew the cells; 
consequently we suffer from the impoverishment. The renewal 
that nature intends to be going on in every part of us is only 
a make-believe renewal, and, in time, tissues and organs, body 
and mind, suffer from the slow starvation of the cells deprived 
of their requisite amount of nutriment. For waste goes on 
continually, whether repair succeeds waste or not, and in pro- 
portion as these unhygienic conditions prevail, various parts, 
and, in time, the whole organism, suffer — the parts naturally 
weakest succumbing earliest, showing, first, disturbances in 
function, and later, organic disintegration. 

We need to consider what the air we breathe is composed of 
in order to understand what ventilation accomplishes. It is 
composed of the gases oxygen and nitrogen, with a small amount 
of carbon dioxide and a variable portion of watery vapor. The 
air we breathe, or in other words, the atmosphere, is invisible, 
yet it is all about us. Being invisible, there is no way of telling 
by the sense of sight whether it is clean and fit to breathe or not. 
The sense of smell helps us somewhat, as very foul air is heavy 
and offensive to a healthy and well- trained olfactory sense; 
but this is too uncertain a guide to depend upon. When we 
grow sleepy and listless and "headachy," even if the sense of 
smell has given no warning, it is safe to assume that the oxygen 
in the air is becoming exhausted, and that we need to furnish 
an outlet for the air that has been breathed again and again, 
and give admission to a fresh supply that nature has purified. 
The gases nitrogen and oxygen mingle together in what is known 
as fresh air, in the proportion of four parts of nitrogen to one of 
oxygen. The gas that is most abundant, nitrogen, cannot 
support life, it is simply used as a diluent or vehicle for the oxy- 
gen, and is weak and inert. The part that gives life, that builds 
up and rejuvenates, that is constantly active, is the oxygen. 
When fresh air enters the lungs it is rich in oxygen, but this is 
quickly appropriated by the blood, and the lungs give off or 
exhale a very different and poisonous gas which is the product 



62 NURSING THE INSANE [Chap. VI 

of the worn-out tissues, carbon dioxide. We need to remember 
the prime necessity for furnishing a continual supply of fresh air 
for ourselves and for the patients. We need also to remember 
that in addition to the air we exhale, which is deprived of its 
oxygen and rendered unfit because of its preponderance of carbon 
dioxide, there are emanations from the skin and from the expired 
breath, and odors from the secretions, micro-organisms, vege- 
table and mineral products, all of which help to vitiate the air. 
Of course this is even more true of sick than of healthy persons, 
hence the added reason why hospital departments shall receive 
extra attention in the matter of regular and systematic ven- 
tilation. Stoves, lamps, and gas jets in operation quickly 
exhaust the fresh air from a room by stealing the oxygen and 
giving off poisonous gases. 

Nature has a wonderful provision for purifying the air, making 
the animal and vegetable kingdoms contribute to the support 
of each other, utilizing what is of no value to one for the benefit 
of the other. Animals need oxygen, and abstract it from the 
air at the same time that they give off carbon dioxide. Plants 
need carbon dioxide; it is their food, as oxygen is ours, and they 
give off oxygen as their waste product through their leaves, 
which act as lungs. Winds and rain also contribute to the 
cleansing of the air. Hence we see that a process is going on in 
nature that is continually purifying the external atmosphere. 
Now what we need to do is to take advantage of nature's work, 
and let our homes and hospitals have the benefit of this purifica- 
tion. This is what ventilation does. It is effected by means 
of doors and windows, fireplaces, chimneys, flues, and other 
special apparatus provided for the purpose. Ventilation in warm 
weather is, of course, a simple matter, but when cold weather 
comes, we have to consider not only supplying the fresh air and 
letting out the stale air, but also warming the fresh supply, so 
that rooms are rendered comfortable and hygienic at the same 
time. 

In ventilating one needs to guard against the fallacy that 
cold air is necessarily pure air, and that warm air is necessarily 
impure. The temperature has nothing to do with the purity 
or the impurity of the air. A room which has not been heated 



Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 63 

or ventilated for weeks may be filled with cold, stale air unfit to 
breathe. A ward does not need to be cold and uncomfortable 
in order to be sanitary. By changing the air frequently and 
closing up between times, the halls can be kept hygienic as well 
as comfortable. Fireplaces are the best means of ventilation, 
but there are few of them in many hospitals, and these few are 
seldom in use. But even when not in use, if kept open, they 
furnish an exit for the impure air. A fire in the grate, by causing 
a constant draught of air to ascend the chimney, and a constant 
quantity of fresh air to descend as well, is one of the most effect- 
ive means of ventilation. When special ventilators are in a 
building, it is the nurse's duty to see that they are always kept 
open. 

The object to be attained in ventilation is to keep air currents 
in circulation all the time without a draught striking the occu- 
pants of the room. In the rooms adjoining the halls, where, 
as a rule, there is but one window, that window should be open 
a little way both at the top and bottom during the night and 
the greater part of the day; not enough to cause a draught, but 
enough to let the warm, impure air go out at the top and the 
cold, pure air come in below. 

To prevent a draught, a four- or six-inch board may be fitted 
across the window sill to cover the opening made by raising 
the lower sash. This admits of the air circulating between the 
sashes. In rooms with two windows opposite each other, open 
one from the bottom and the other from the top. Remember 
that the smaller your rooms are, the greater is the need for fre- 
quent ventilation, and that with a large number of people con- 
gregated in a given room, the need for frequently supplying them 
with fresh air is correspondingly great. Rooms which have a 
transom furnish additional means for ventilation. The rooms 
into which they open, however, need to have the air changed 
from time to time. 

Halls and sitting rooms are easily ventilated by opening op- 
posite windows, above and below. As a rule, except in severe 
weather, these may have small openings all the time, care being 
taken to throw the windows wide open at intervals, and always 
when patients are at meals, and so admit of a free circulation 



64 NURSING THE INSANE [Chap. VI 

and entire change of air. By closing the windows entirely for a 
while after these thorough airings, the halls soon become warm 
and comfortable, yet the occupants have a fresh supply of air 
to draw from. The nurse in charge should train her assistants 
to see that this change of air in the rooms, halls, and sitting 
rooms is regularly and systematically attended to. The dining 
rooms should be thoroughly ventilated by throwing up the win- 
dows from the bottom and pulling them down from the top for 
fifteen or twenty minutes after each meal; then some smaller 
openings in opposite windows may be maintained nearly all of 
the time, the windows being closed only in severe weather, long 
enough before meals to insure the comfortable heating of the 
room. It is cheerless, and unnecessary, as a rule, to have to 
eat in a cold dining room. 

In summer, attention should be paid to keeping the dining 
rooms darkened and cool by drawing the shades and having 
the windows opened to their limit between meals, but when at 
meals, the shades should be raised and the room made as attract- 
ive as cleanliness, fresh air, sunlight, and painstaking arrange- 
ment of the tables and food can make it. Potted plants, a few 
wild flowers or grasses, a spray of autumn leaves, lend a touch 
to the tables that the dining-room attendant who takes a genuine 
interest in her work is sure to call to her aid. 

There are a few, but only a few, instances when it does not 
seem wise to ventilate a room directly by permitting the ingress 
of fresh air from outdoors. In such cases, do not make the mis- 
take of opening a door into a cold hall or adjoining room and 
think that you are supplying pure air. First directly ventilate 
the room from which you are to draw your supply, making sure 
that the air in that is thoroughly renovated, and warmed, if need 
be, then open the door between the room you wish to ventilate 
and the one you have already ventilated, and your patient can 
thus get the benefit of the interchange of air between the two 
rooms. 

Nurses have to combat all kinds of prejudice against pure air; 
some patients will put down a window as often as the nurse can 
put it up. It is not always easy to deal with these difficulties. 
Individual cases call for various ways of handling. Infinite 



Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 65 

tact and patience, a painstaking explanation in some cases, 
persistence in others, and a gentle but firm reminder that the 
rules of the institution in this respect must be obeyed, will usu- 
ally make the patient feel that he must conquer his prejudices 
against fresh air, or at least submit to the sanitary regulations 
of the hospital; and this is, of course, far better than to have 
him feel that the nurse insists on keeping the windows open 
to have her own way, or just to spite the patient. 

Take advantage of opportunities to air the rooms of patients 
when they leave them for meals, to go out walking, and the like. 
Sewing rooms, dormitories, clothes rooms, bathrooms and water- 
closets should receive systematic attention in this all-important 
matter. 

There are various means of artificial ventilation, either by 
heat currents, as fireplaces and basement furnaces (dependent 
on the fact that air, when heated, expands and becomes lighter, 
and so rises), or by forcibly drawing the air into rooms with fans, 
or by suction by a pumping apparatus. Rooms heated by fur- 
naces have the disadvantage of all the moisture being withdrawn 
from the air. In such rooms dishes of water should be kept. Nurses 
need to familiarize themselves with whatever means of heating 
and ventilation are in use in the institutions or the homes where 
they are employed, whether it be stoves or furnaces, steam or hot 
water, direct or indirect radiation, and in each case should learn 
how to control and regulate them. 

In the hospital departments, as has been said, the need for 
frequent and effectual ventilation is much greater than on the 
wards. Patients are congregated there day and night, they are 
sick in body as well as in mind, their exhalations are more foul 
than those of persons with sound bodies ; evacuations are frequent, 
and, even with the utmost precaution, they contaminate the air. 
In such rooms, then, it is imperative that exits for foul air and 
entrances for fresh air be in continual operation, day and night. 
In addition to this, windows should be widely thrown up and 
pulled down frequently in the course of the forenoon and after- 
noon, and during the night, especially after evacuations of the 
bowels and bladder, and after dressings have been made. Soiled 
and infected linen and dressings should be promptly removed 



66 NURSING THE INSANE [Chap. VI 

from the hospital. Vomited matter, evacuations from the bowels 
and bladder, should be covered with a towel or a rubber cloth 
and promptly carried from the room, expectorated matter should 
be collected in sputum cups whenever possible, and when not, 
in a paper napkin which is to be disinfected and put in the water 
closet immediately if it cannot be promptly burned; in the case 
of patients who cannot be trained to use either cup or paper, 
eternal vigilance must be exercised, to wipe up the sputum 
immediately and dispose of the contaminated paper by immediate 
burning, or in the water closet. 

Precautions should be taken to cover the patients especially 
well when thorough ventilation is in progress, by pulling the covers 
over the head if need be, using extra blankets, and placing 
screens for protection. But thorough ventilation there must be. 
It is of far more value than medicine. In many cases it is the 
most efficacious remedy we can employ. For continuous venti- 
lation it is well to remember that several windows opened a little 
are more effective than one or two opened a good deal. 

There still exists in the minds of many the erroneous notion 
that the air of a room can be purified by creating an odor to 
cover up the odor already there. Various fumigating powders, 
incense sticks, pastilles, and the like, are employed with this 
object in view. They may cover up an odor; they can never 
purify. They cannot remove the carbon dioxide from the air, 
nor supply the needed oxygen. 

The temperature of the wards and rooms needs to be higher 
than that of the hospitals — 68° to 70° F. for sedentary persons, 
while 65° to 68° F. is usually ample for patients lying in bed con- 
tinually; although anemic, feeble, and consumptive patients 
need a higher temperature (70° F.) than well-nourished bed 
patients, and fever patients need less than any others — 60° to 
65° F. usually. 

The halls and hospitals are provided with thermometers for 
registering the temperature of the room. These should be hung 
at central points in the room or ward, and not near a gas or 
electric light or a window. It is the duty of the charge nurse 
to watch the registering of the thermometer every hour, to record 
its registering as often as the rules of the institution require, 



Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 67 

and to be guided by it in regulating the temperature of the ward, 
taking immediate steps to remedy the temperature that is too 
high or too low, by increasing or decreasing the supply of heat. 

As we need to consider the maintaining of warmth in the sick 
room in winter, we also need to consider means for cooling it in 
summer. By keeping windows open as far as possible, above 
and below, all night, then closing or nearly closing them about 
8 a.m. for several hours during the hottest part of the day, the 
heat can be somewhat diminished. Fresh air must then be 
secured indirectly from adjoining rooms, when the plan of ad- 
mitting no out-of-door air is adopted. By judicious arrange- 
ment of shutters and dark shades, the heat can be appreciably 
lessened. When the heat is extreme, large blocks of ice placed 
in shallow tubs, sheets wrung out of hot water and hung before 
the open windows, spraying with Cologne water, and placing 
large branches of trees in jars of water in the room, are means 
to lessen the suffering. 

In addition to ventilation and an equable temperature of the 
wards and hospitals, the importance of sunlight needs to be 
emphasized. Sunlight is a purifier. There are few conditions 
in which an abundance of sunlight in the room is not decidedly 
beneficial. In certain difficulties with the eyes, the light needs 
to be subdued, or the room even darkened, but in most cases 
the sun should be welcomed as a potent means of health and 
cheer. Care must be taken, though, to see that the rays do not 
fall across a patient's face, and that his bed is not so placed that 
he faces a glare of any kind. Nurses need to remember that the 
sunlight changes its position, and that a patient whose bed is 
comfortably placed at 3 p.m. may need later to be protected from 
the shifting afternoon light by a proper arrangement of shades 
and shutters. A nurse should be chagrined to have her attention 
called to helpless demented patients who lie winking, blinking, 
and sweltering in the afternoon because of her neglect to lower 
a shade, or change its position, or even the position of the bed, 
if the difficulty can be remedied in no other way. Sometimes 
the window shades blow out, letting bands of light come through 
the sides, and in order to get the benefit of the air the nurse lets 
the shades flop, even though the sunlight streams into the eyes 



68 NUKSING THE INSANE [Chap. VI 

of some patient. Simply pulling the bed out of line for a while 
will obviate the difficulty in many instances. 

Next to ventilation and the maintenance of a suitable tem- 
perature and an abundance of sunlight, we need to consider 
the means for cleanliness of the halls and various rooms, and 
the hospital departments. The nurse in charge should have the 
work arranged and apportioned in a systematic way, each of her 
helpers having her stated daily tasks. Carpeted rooms need 
to be swept with damp brooms, care being taken always to 
sweep with the broom near the floor and not to flirt the dust 
about; walls and ceilings require frequent washing; rugs need 
to be vigorously brushed and shaken out of doors, bedsteads 
carefully cleaned and inspected every week, mattresses and bed- 
ding are to be kept clean and in repair, the muslin coverings of 
screens immaculate; the tops of wardrobes, bureaus, stand and 
commode drawers should be kept free from food, refuse, and 
rubbish. Repairs of furniture call for prompt attention; creak- 
ing hinges are to be oiled; rattling windows made quiet; torn 
shades mended; worn curtains and rugs darned; windows and 
mirrors polished; in short, systematic attention must be given 
to all the details of hygienic housekeeping. 

The thorough and systematic daily airing of the beds must 
never be neglected. In order to air a bed properly, each article 
needs to be removed separately, shaken and spread out on the 
backs of two chairs if possible, the mattress uncovered, the pil- 
lows beaten, and the bedding subjected to a thorough airing. 
With pains being taken in this particular, many of the patients 
can be trained to this task regularly and well. If they cannot be 
so trained, the nurse must make it a matter of her daily attention. 
It is desirable that a bed shall air at least two hours before being 
made up for the day. In dormitories where it is the custom 
not to make the beds up until night, the mattresses are left 
exposed, and the bedding arranged in various systematic and 
orderly ways, according to the customs in vogue in given depart- 
ments. Whatever secures the most thorough ventilation is the 
most desirable. 

In the hospital departments the duties are very different from 
those concerning the care of the halls, sitting rooms, and rooms 



Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 69 

occupied by patients not requiring bed care. Here, as before 
stated, we have to deal with large rooms occupied by patients 
day and night, and the necessary ventilation, cleaning, and 
putting to rights has, as a rule, to be done while the patients 
are in bed in the rooms. Of course during the semiannual and 
annual housecleaning patients are usually temporarily transferred 
to adjoining wards, but during the daily and weekly cleaning, 
the matter is complicated by having to keep constantly in mind 
the comfort and welfare of your patients. The proper removal 
of dust, which is the source of so much disease, is one of the chief 
things to be considered; it must be removed so quietly and 
effectively that your patients are not inconvenienced by the 
process. To this end the tops of windows and door casings, the 
woodwork generally, picture frames, and all dust-collecting sur- 
faces must be wiped daily with damp cloths, and the floors 
brushed with hair brooms, and then dusted with damp cloths 
wrapped around the brooms. No more water than absolutely 
necessary should be put on the floors, as water only tends to 
destroy the floor dressings and so render the floors a source of 
danger, because of their absorption of impurities. 

When water is used to cleanse the floors, it should be frequently 
changed, and should contain whatever disinfectant for the pur- 
pose is in vogue in the institution. The use of disinfectants will 
vary in different institutions and in different parts of the same 
institution. Dust cloths need to be frequently wrung out of a 
weak solution of carbolic acid which should be changed often, 
and the cloths cleansed in hot soapsuds and a carbolic solution 
before being put away in the drying room. All mops and clean- 
ing cloths should receive the same careful attention. If a floor 
dressing of turpentine and wax is used, it is applied with a 
flannel pad, and needs to be used every ten days or two weeks 
to keep the floors in good condition. Instead of this dressing, 
crude oil is often rubbed in the floors, and the excess rubbed 
off with the flannel polishers. Especial care must be exercised 
with oiled rags and cloths used for this purpose, because of the 
danger of fire from them if they are allowed to lie in a heap. 
They must be immediately rendered safe by washing, or promptly 
burned. 



70 NURSING THE INSANE [Chap. VI 

When the help of able-bodied patients is enlisted in the work 
of sweeping, dusting, and cleaning, it is of the utmost importance 
that such work be carefully supervised by the nurse in order to 
prevent negligence, the throwing of dust, the soaking of floors, 
the jerking of beds, and other injuries and annoyances to ill and 
helpless patients. 

If the nurse in charge requires of her subordinates care and 
consideration in these matters, the patients will often find, in the 
orderly and systematic putting to rights of the ward, a source of 
daily interest instead of a disorderly, dust-choking scene of con- 
fusion, such as obtains where system and attention to details are 
wanting. 

Beds must be frequently aired and sunned, mattresses brushed 
vigorously with a whisk broom at least once in two weeks, and 
bedsteads washed with a weak carbolic solution. On wards 
where the patients are unclean, this cleansing of the bedsteads 
needs to be much more frequent, on some even a matter of 
daily attention. 

Especial vigilance concerning vermin is needed after admis- 
sions, and also immediately after the visits of persons whose 
appearance makes one suspect that they may be the carriers of 
these pests. This must, however, be done tactfully, so as not 
to give offense to the patients who have just been admitted or 
visited. 

All soiled clothing, bedding, and dressings should be removed 
promptly from the hospitals and placed in the closed receptacles 
provided for them, until they can be put in the clothes chutes 
for collection by the laundrymen, or in the dust chutes for 
destruction by fire. Remove all pins from clothing, and all 
fecal matter, roll the very dirty articles in bundles by themselves, 
and make out duplicate lists of all articles sent to the laundry, 
retaining one for comparison on the return of the clothes. 

Especial care must be given to all vessels and utensils used in 
the hospitals, lavatories, and bathrooms. These should never 
be put away until thoroughly cleansed, and the basins, hoppers, 
water-closets, and bath tubs require the most diligent attention 
to keep them clean and free from odors or contaminations. 
Your patients will often be careless about flushing the closets. 






Chap. VI] HYGIENE OF WARDS AND INFIRMARIES 71 

Their negligence must be promptly followed up by the nurse. 
Any failure of the closets to flush properly, or any defect in the 
drainage, should be reported at once to the engineer. Excretions 
should not be allowed to stand in the vessels at any time, day or 
night, when nurses are at hand to empty them. But in the rooms 
and dormitories, between the rounds of the night nurses, this is 
sometimes unavoidable. The nurse should, however, encourage 
patients to cover the vessels until such a time as she makes her 
next round. 

Food or dishes which have contained food and medicines, as 
a rule, should not be allowed to remain in the rooms or hos- 
pital departments. Trays, cups, glasses, are to be immedi- 
ately removed and cleansed after using. Withered flowers, stale 
water in flower jars, and plants that have ceased to be decorative, 
are to be promptly removed from the wards, rooms, and hospital 
departments. 

The bedding should, of course, be changed as often as it is 
soiled, day or night, and pride taken to prevent the mattress and 
pillow tickings from becoming stained, the blankets and coun- 
terpanes from becoming soiled or torn, and the rubber sheets 
from being cracked, pinned through, folded, or injured in any 
way. 

Soiled mattresses and blankets unfit for use should be sterilized 
and put away until a sufficient number have collected to be sent 
away to be cleaned. 

Window ledges and fire escapes are to be carefully inspected, 
to the end that decaying fruit, food, excreta, and rubbish are 
not allowed to collect there, and especial pains should be exer- 
cised both day and night, that patients do not get an opportunity 
to throw these things, or articles of clothing, or anything from 
the windows. Hallways and stairways, mop closets, drying 
rooms, linen rooms — every nook and corner needs constant 
supervision. 

Inspection day is a day set apart once a week when the phy- 
sicians take especial pains to see that perfect order and cleanliness 
prevail. On other days in the week it is the duty of the super- 
visors to make this matter one of close attention. On regular 
inspection days the drawers of bureaus and commodes, the doors 



72 NURSING THE INSANE [Chap. VI 

to wardrobes, and closet doors are to be left open so that the 
interiors can be readily inspected. This is not for the benefit 
of the physicians. Aside from the object of keeping the wards 
up to the highest standard of hygiene, it has its value in dis- 
ciplining the nurses and patients to regular and systematic 
attention to orderliness; it prevents the accumulation of rub- 
bish, and it enables the nurses to discover purloined articles 
which certain patients are prone to hide away, but which cannot 
long go undiscovered if this weekly putting to rights is rigor- 
ously attended to. 



CHAPTER VII 

THE CAEE OP BED PATIENTS 

Bed treatment is one of the most efficient means of building up 
the sick; notably those who are unsound of mind as well as of 
body. 

In order to be truly efficacious, certain requirements concern- 
ing bed treatment must be met. The bed must be clean and 
comfortable. To be clean means that the bedstead, springs, 
mattress, mattress protector, sheets, blankets, coverlid, pillows, 
and pillow slips shall all be clean and well aired. To be com- 
fortable means that a good article be purchased, the springs and 
mattress renovated as often as necessary, and the furnishings 
sufficient, clean, and arranged in an orderly manner. 

For the sick the ideal bed is a single iron one, white enameled, 
and with double woven-wire springs, and a hair or high grade 
" felt " mattress. The bedstead should, of course, be on casters, 
and should, if possible, be so placed that the nurse can approach 
it from all sides. If a bed is found to be too easily moved, by 
reason of the casters, thus annoying the patient, the ones at the 
foot of the bed may be removed and still the bed be easily man- 
aged. Casters which do not move easily, or which squeak, need 
to be oiled and kept free from dust and other accumulations. 
Beds in hospitals require the most scrupulous care to prevent bed- 
bugs from getting any start in them. The frequent examina- 
tion of bedstead, springs, and mattress, and the regular cleansing 
of them, are among the regular, never-to-be-neglected duties of 
the nurse. A weekly going over the bedsteads with a disinfectant 
and a careful insertion into all the joints and crevices of tooth- 
picks dipped in carbolic solution have been found effectual 
means of getting rid and keeping rid of these pests. 

Most hospital beds are supplied with two pillows, one of hair 

73 



74 NURSING THE INSANE [Chap. VII 

and one of feathers. The bed covering should be light but 
sufficiently warm, the sheets preferably of cotton, and either a 
very light-weight counterpane, or a white sheet used as a cov- 
erlid. 

In selecting mattresses for your patients, take pains to select 
the best and most even mattresses for the ones who have to be 
most constantly in bed, and of course report for disuse all lumpy, 
uncomfortable mattresses or worn-out springs. 

In many of the hospital departments it is necessary to protect 
the mattress by large rubber sheets covering the middle third, 
or even in some cases the entire length of it. These are expen- 
sive articles, and in addition to the painstaking care necessary 
to keep them hygienic by daily airing, and by cleansing as often 
as necessary, it is important to see that they are never folded 
or creased in any way, as this ruins them. They should be 
rolled when not in use. Pins should never be put in them. 
Stains not easily removed by water may often be removed by 
Labarraque's solution or by hydrogen peroxide. Sanitas or 
some other disinfectant is used on them daily. 

Two ways of making the beds in reference to the use of the 
rubber sheet are commonly in vogue, some nurses claiming to 
get the better results with one, some with the other. The width 
of the mattress and the class of patients have to be taken into 
consideration; whichever method gives the best results should 
be employed. 

The one that seems to me to give the best results is to cover 
the mattress first with the lower sheet, tucking it in as elsewhere 
described. Then place the large rubber sheet crosswise the 
bed in its middle third, fastening it securely by fitting it well 
around the mattress underneath, every part of it above and below 
the mattress being smoothly spread out. Over the rubber sheet 
place a folded sheet or draw sheet, with the hems placed at the 
bottom, if necessary pinning its four corners to the under side 
of the mattress. By this method, when the draw sheet is soiled, 
it can be removed, and the rubber sheet cleansed while remaining 
in place, and a fresh draw sheet applied, without the necessity for 
changing the lower sheet. 

The upper sheet is put on the bed with its right side facing the 



Chap. VII] THE CARE OF BED PATIENTS 75 

right side of the lower sheet, and with its wide hem at the top. 
This needs to be well tucked in at the foot, and enough of it left 
at the top to turn down over the tops of the blankets so as to 
protect them from becoming soiled, and also in order to keep the 
wool from coming in contact with the face. Double blankets 
should always be separated, as they are otherwise unwieldy. 
Blankets are allowed to come up high enough to admit of being 
tucked in snugly around the neck; care should be taken not to 
tuck the coverings in so tightly over the patient's toes as to cause 
discomfort. If sheets or blankets are too long, tuck the surplus 
in at the foot of the bed. Counterpanes should be removed at 
night, neatly folded, and so placed in orderly piles that they may 
be put back the next day on the same beds from which they were 
taken. 

The beds in the hospitals should present as uniform an appear- 
ance as possible, the spreads put on evenly, the corners neatly 
arranged, the pillows similarly placed, and the bedsteads arranged 
in line. There are usually on every ward convalescent or chronic 
patients who can be trained to take pride in the neat and uni- 
form appearance of the beds; such occupation should be encour- 
aged when the patient's condition admits of it. 

Stains on mattresses and blankets should be avoided as far as 
possible. When blood stains get on the ticking of mattress or 
pillow, one or two applications of a paste of starch or wheat flour, 
applied and allowed to dry, will usually remove them. Other 
stains may, as a 'rule, be removed with soap and water, or ammo- 
nia water. When the mattresses become badly discolored and 
stained, the stained parts should be cut out, and fresh ticking 
neatly set in. 

In changing the bed linen the comfort of the patient should 
be the first consideration. Have everything in readiness, close 
at hand before beginning. Of course in many cases patients are 
able to sit in reclining chairs while this is done, which is desirable 
if the patient's condition warrants it, not only because the up- 
right position and the change are a relief to the patient, but also 
because his removal from the bed admits of turning and shaking 
up the mattress and ventilating it in a way impossible if the bed 
must be changed with the patient on it. Very feeble patients 



76 NURSING THE INSANE [Chap. VII 

may be lifted on to another bed while their own is being changed, 
but in some cases it is necessary to change the bed with the 
patient remaining on it. 

Those who have to stay habitually in bed should have a frequent 
change of mattress, the one after constant use being brushed, 
aired, and sunned for prolonged periods when not in use, while 
the other is substituted. If the patient is very ill and weak, 
matters are facilitated by having two nurses do the work of 
changing the bed ; but if not, one deft and systematic nurse can 
accomplish it easily. 

First, remove the pillows. The upper sheet and one blanket 
are left over the patient. Loosen the lower sheet and draw 
sheet at the top, bottom, and sides; from the side of the bed 
farthest from the patient the sheet is then folded lengthwise and 
as flatly as possible close up to the patient's back; fresh sheets 
folded lengthwise, alternately backward and forward for half 
their width, are placed close up to the folded soiled sheet, and the 
unfolded half of the fresh sheet is smoothly laid on the side of 
the bed from which the soiled one has been taken, and firmly 
tucked in at the side. The patient is then turned over on the 
clean sheet, the soiled sheets and the folded clean ones being 
drawn underneath, the fresh ones being smoothed out and 
tucked in at sides and both ends, and the soiled ones gathered 
in a heap on the floor to be quickly removed to the proper recep- 
tacles for them outside. 

In cases where the patient cannot be turned on one side, it is 
necessary to lift him, while another draws the soiled, then fresh, 
sheets underneath him. In other cases, a bed may be drawn 
close up to the bed to be changed, and the patient gently rolled 
from one to the other, the bed then being drawn away and 
quickly fitted up with fresh sheets, then drawn back, and the 
patient again gently rolled or lifted on to the fresh bed. Or he 
may be lifted from one to the other in a strong under sheet. In 
moving a patient from the bed to a reclining chair, always place 
the chair with its back toward the bed. 

In cases where it is needful to lift a patient from one bed to 
another, one person of ordinary strength who knows how to do 
it can easily manage with a patient of average weight, provided 



Chap. VII] THE CARE OF BED PATIENTS 77 

he can cooperate a little. Place the head of the empty bed at 
the foot of the one occupied. Throw back the coverlids of both 
beds, and see that the patient's nightgown is well drawn down. 
Stand at the right of the patient, bend your knees, bring your 
right arm as far as possible under the patient, so that the upper 
part of his thighs rests upon it; then pass your left arm under 
the middle of his back to the other side; have him put his arms 
around your neck, and tell him to let his knees hang limp. Then 
lift him as you straighten your own knees and rise, bend yourself 
back so that the body of the patient lies upon your chest. Then 
carry him to the empty bed, taking great care to lower him 
gently to the middle of it, if possible having a second person stand- 
ing at the opposite side of the empty bed, receiving part of the 
weight of the patient under your arms, so that he is gradually 
and gently lowered to the bed instead of being dropped there 
with uncomfortable suddenness. 

With unconscious patients a second person needs to support 
the head; where a foot or a leg is injured, the injured member 
must be supported by another. 

There are cases where it is necessary to change the bed linen 
from the top. In doing this, loosen the lower sheet at top and 
sides and push well down under the pillow. Have some one else 
stand at the opposite side of the bed and work down the soiled 
sheet, followed closely by the folded fresh one, raising in turn the 
shoulders, back, and hips with one hand, while working down 
the sheets with the other hand. 

To change the upper sheet, free the clothes at the foot of the 
bed, spread the clean sheet over them, and a fresh blanket over 
that, tuck them in securely at the foot, and then draw out the 
soiled sheet and blanket from beneath, the patient not being 
uncovered at all during the process. If the sheet only is to be 
changed, the clean sheet may be folded across its width, tucked 
in at the bottom, and unrolled toward the top, the soiled sheet 
then being pulled down and removed at the foot. 

It is a real boon to the sick to have pillows arranged comfort- 
ably. In changing pillows, the head of the patient is lifted and 
supported by the nurse's arm, the back is supported by the 
hand. The other hand turns the pillow, the lower pillow being 



78 NURSING THE INSANE [Chap. VII 

brought under the shoulders to support the back, the upper one 
to support the head. In lowering a patient's head, do it gently, 
not letting it drop back with a jerk. It is well if possible to 
have two sets of pillows, or at least three pillows, if four are not 
accessible. In this way the patient has the benefit of a fresh 
pillow frequently, while one is always being aired. If this is not 
convenient, as you remove the heated pillow take it away from 
the bed, shake it, change the slip, if necessary, pulling up the 
second pillow in its place, which in turn is taken and made fresh 
by a clean slip and by shaking. 

When wishing to prop up a patient in bed in a half-reclining 
position, if you have none of the mechanical head rests or appli- 
ances for the purpose, a fairly comfortable one can be impro- 
vised by placing a straight-backed chair upside down in the bed, 
and arranging pillows on it, against which the patient can rest. 
Tuck a hair pillow low down against the small of the back, place 
another to support the upper part of the back and the shoulders, 
then a small cushion for the head at the top. In propping up 
with pillows alone, more pillows are needed. Crowd the lowest 
one well down against the small of the back, then put each addi- 
tional pillow behind the last one, to prevent slipping. Patients 
inclined to slip down in bed need to be frequently raised back 
to the proper position, not by tugging at them from under the 
arms, but by sliding your arms under the hips, and having them 
aid you by pressing with hands and heels against the bed. Plac- 
ing a hassock or a circular cushion at the foot of the bed to brace 
against will help in some cases, and in others placing a long firm 
roller pillow under the buttocks, the roller having tapes at each 
end which are tied securely at the head of the bed, will obviate 
this difficulty. Or roll a blanket or a light quilt in the required 
shape, covering with a pillow or bolster case to keep clean. 
There are other appliances which add greatly to the comfort of 
bed patients, such as knee pads, cotton and oakum rings for the 
heels, rubber air cushions, air and water beds, cradles for pro- 
tecting the patient from the weight of the bedclothes, and the 
like. When cradles are used in the bed, they should always be 
placed under the blankets, the top sheet alone immediately 
covering the patient. 



Chap. VII] THE CARE OF BED PATIENTS 79 

If no regular cradle can be procured, the nurse can improvise 
one which answers the purpose by joining two barrel hoops in the 
middle, and arranging them on the bed so as to remove the weight 
of the clothes from the body. 

Helpless patients need to have their positions in bed altered 
from time to time, even when it is not a question of changing the 
beds or of adjusting the pillows. When necessary to do this, the 
nurse passes her arms well underneath the knees and shoulders 
of the patient. In other cases, very heavy patients may be moved 
and turned over on one side by means of the draw sheet. 

All sheets and pillow slips should be well aired and thoroughly 
dry, and in cold weather warmed before placing on the bed. Bed- 
ding should be changed as often as soiled. By exercising con- 
stant supervision over untidy patients, to see that the rubber 
sheets and draw sheets are kept in place, and that the bed pan 
or the commode is frequently resorted to, the necessity of chang- 
ing the bedding can be greatly reduced; and even in cases where 
the patients will not use commode or pan, the lower sheet need 
not in many cases be interfered with if the draw sheet and its 
waterproof sheet beneath be promptly changed before the lower 
sheet has time to become soiled. 

When an abundance of bed linen is provided, it is not necessary 
to resort to the make-shift custom of using the crumpled upper 
sheet in place of the soiled lower one; but there are conditions 
where strict economy in the laundry work has to be practiced, 
and there are times when you will be short of the regular supply. 
At such times, shaking out, airing, and thoroughly heating the 
sheets that still have to be used, will do much to renovate them 
until you can obtain a fresh supply. Sometimes shaking and 
smoothing the upper sheet, and using it for a draw sheet will 
do nicely. One needs always to remember, however, that par- 
ticles of worn-out skin, moisture, and emanations from the body 
are absorbed by the sheets, as well as by the patient's clothing, 
and that their frequent cleansing by washing is imperative, even 
when there are no stains or dust, or other visible signs of un- 
cleanliness on them. When you cannot have fresh sheets as 
often as you would like, remember that keeping them pulled 
tight and straight on the bed, frequently pulling down the pa- 



80 NURSING THE INSANE [Chap. VII 

tient's nightgown, to free it from wrinkles, as well as bathing 
his back with alcohol, will do much to freshen the bed and refresh 
the patient. Add to this the practice of lifting the bedclothes 
from the edges and fanning them gently up and down, letting in 
the fresh air, and letting out the foul emanations from the pa- 
tient's body, which practice will do a great deal to keep the bed 
hygienic and to render the patient comfortable. 

Beds need to be brushed free of crumbs after every meal, the 
wrinkles smoothed out, and the upper clothing adjusted in an 
orderly way. 

There is a tendency among insane bed patients to secrete 
things in bed — letters, spectacles, combs and brushes, tooth 
brushes, soap, and in the less tidy ones, food, rubbish, and even 
filth. The proper care of the beds requires that nothing be 
allowed in them except the bedding, the legitimate appliances 
as called for, and the patients. To help the patient in her very 
natural desire to have her personal belongings near her, and so 
guard against their use by others, it is perfectly admissible to 
allow her to have a little cotton bag which can be hung by its 
gathering string at the head of her bed, and in this her toilet 
articles, and such other belongings as she wishes, may be put. 
This can be kept presentable by laundering when necessary. 
The brushes and combs of patients less fastidious may be kept 
in the drawers provided for the purpose, and the tooth brushes, 
marked with the patients' names, in the racks arranged for them. 
Some patients provide their individual syringes, or at least the 
nozzles for them, also hot-water bags, and other appliances. 
When this is done, the nurse should be conscientious in keeping 
these articles set apart for the exclusive use of the ones to whom 
they belong. The individual wash cloths of patients, after being 
used, should be rinsed in hot water, and hung on the heads of the 
beds to air, not tucked under pillows nor put into drawers, nor into 
the bags heretofore mentioned, until they are thoroughly dried. 

Where one has a choice, the sick bed should be placed so that 
it can be approached from all sides (but never in any case close up 
to the wall) ; it should be in a light, pleasant part of the room, but 
never facing a glare of light; and, if possible, so that an outlook 
of tree and sky may be obtained. 



Chap. VII] THE CARE OF BED PATIENTS 81 

In hospital departments where there are many beds, the 
arrangement must be made advantageous, all things considered, 
to the greatest number, always remembering to give the most 
desirable places to those closely confined to their beds; the least 
exposed places to the aged and feeble; the least conspicuous to 
the untidy and unsightly ones, with due regard to the proximity 
of the lavatories for those who frequent them most, especially if 
difficulty in locomotion is experienced. Many patients prefer to 
help themselves in these matters, rather than to be waited on in 
bed; when able to do so, this should be encouraged. Bath robes 
and slippers should be at hand, and patients trained to use them in 
going to and from the water sections. 

Convalescent patients and some others are able to be up and 
dressed throughout the day, but for one reason and another need 
to sleep in the hospitals. Such patients, when able, should be 
trained to air their beds on rising from them, taking off each 
article separately, shaking it, and exposing each to as free access 
of air as possible, leaving the bedding exposed till after break- 
fast, when the beds are to be made up for the day. 

Convalescents and certain able-bodied chronic patients are 
often of distinct service in helping to care for helpless patients. 
Great care, however, needs to be exercised in supervising their 
work, to see that it is done well. Some well-meaning ones, will- 
ing, but lacking in judgment, will, unless watched, jerk the beds 
about, brush or lean against them in a way to jar or push them, 
sit or loll on them, when occupied by others, put trays on them 
instead of on the bed tables or stands provided, or, if they be 
allowed to feed others, may feed too rapidly, or in other ways 
prove inefficient. Press such patients as are permitted to work 
into your service when they can be trained to render efficient 
service (you will often find them more deft and tractable than 
some of your assistants), but always remember, however trusty 
you think them, to keep a watchful eye upon their work; and 
also remember that a little extra time spent in training them to 
do things properly will be more than made up in the long run. 

The Toilet of the Bed Patient. — When the hospital nurse first 
comes on duty in the morning, after receiving the verbal and 
written reports of anything unusual in the night (more par- 



82 NURSING THE INSANE [Chap. VII 

ticularly concerning all cases especially sick), the first thing is 
to wash the faces and hands and comb the hair of the patients 
not able or not to be depended upon to do these things for them- 
selves. Each nurse in a given division has her regular patients 
to look after, assigned her by the nurse in charge; she should 
have her toilet basket with the necessary articles ready, with 
everything to be used at hand before beginning each toilet. The 
details of bathing a patient are considered in another chapter. 
In this first toilet of the patient all the little niceties cannot be 
attended to, the main thing now being to render the patient 
presentable before receiving her tray. The full toilet of a pa- 
tient takes more time, and at this busy hour of serving break- 
fast, is out of place; besides, most patients are too weak in the 
morning to be fussed over very much till after breakfast. 

For the hasty first toilet, then, have the water, soap, towels, 
wash cloth, brush and comb all ready before beginning on a 
given case. Try to find something cheerful to say while quickly 
but gently performing this morning service; dry the skin care- 
fully, and patiently and gently disentangle the hair. Long and 
heavy hair should be braided in two braids, well brought over 
to the sides of the head. If it is very much entangled, it must 
be separated into small portions and gently worked with until 
the snarls are removed. Do not tire your patient, if she is weak, 
by attempting to get the snarls all out at one time. Daily atten- 
tion to the hair will, as a rule, prevent such matting as is here 
mentioned, but patients are often admitted with the hair in such 
a state, and time and patience are required to get it in a proper 
condition. In combing or brushing the hair, after brushing it 
gently away from the patient's face, so that no stray hairs fall 
over the face, grasp the long hair in the left hand, begin at the 
ends and work gradually upward, keeping the head steady and 
holding the hair so that, even when it is snarled badly, your efforts 
at disentangling will not hurt or jerk the patient. This can be 
done if you will go slowly, taking the hair in sections. Dress the 
hair before changing the bed linen, and take pains at all times 
to keep the bed and clothing of the patient free from loose hairs. 
The beards of male patients should be neatly brushed, and fre- 
quently washed and rinsed to keep them in a proper condition. 



Chap. VII] THE CARE OF BED PATIENTS 83 

Patients who are able should be trained, if not accustomed to 
do so, to brush their teeth at least once a day. The weak and 
helpless should have their mouths attended to carefully at the 
bedside, the mouth cup with listerine or some cleansing mouth 
wash being brought to them with the basin to receive the rins- 
ings; they should then brush their teeth and tongue or have 
them brushed; if this attention to the care of the mouth be 
given not only in the morning but after dinner and again at night 
before retiring, and the hands and face also bathed at those 
times, the increased comfort to the patient will repay the nurse 
for the extra trouble that it entails. The lips and mouths of 
fever patients and some others require frequent cleansing and 
moistening throughout the day to remove the rapid accumula- 
tion of sordes. 

I realize that in our large hospital wards and with a large 
number of irrational and often very troublesome patients, some 
of these niceties of the toilet, especially in certain cases, seem 
rather too much to undertake. One cannot be dogmatic, and 
say that it shall be done in all the departments and with all 
patients; but even the most obstreperous cases should be pa- 
tiently and persistently worked with till they will either brush 
their teeth once a day, at least, or let you do it for them. 

Patients in bed, as a rule, need only an undervest and a night- 
gown or nightshirt on. The weight of the undervest should, of 
course, vary with the varying weather. This, as well as the night- 
gown, should be changed frequently, and, when practicable, one 
gown and shirt kept for day and another set for nightly use. In 
summer weather it is better in most cases to dispense with the 
undervest. There are a few aged and feeble patients who in 
severe weather, because of poor circulation, will need stockings 
and even underdrawers on in bed, but as a rule most patients 
can dispense with this extra clothing and be the better for it, if 
due attention be given to the temperature of the ward, to suffi- 
cient bed coverings, and to the use of hot-water bags. 

Patients who are able to sit up in bed, or who wish to have 
their arms out a good deal, are made more comfortable if pro- 
vided with bed jackets, kimono sacks, shoulder shawls, Nightin- 
gale wraps, and the like. The friends are often eager to furnish 



84 NURSING THE INSANE [Chap. VII 

these conveniences if you will but remind them of the need. 
Blanket wrappers, bath robes, and kimonos, with bedroom 
or bath slippers, are comforts which can frequently be procured 
for the asking. These should be kept near at hand and used 
exclusively for the patient for whom they are provided. The 
blanket bath robes and slippers, supplied by the institution 
for patients not provided with these conveniences, should be 
more systematically used than they are in some departments. 
This can be done if the nurses will work together to encourage 
patients to use these things instead of letting them jump out 
of bed and run to the section barefooted and in their night 
clothes. When patients sit in a reclining chair, their feet and 
legs should be covered with gray blankets kept for the purpose, 
or a lighter covering in mild weather. 

Patients accustomed to soil the bed should be given short 
nightgowns, but a nurse who exercises systematic vigilance 
in such cases can usually break up the habit of uncleanliness, 
and should be ashamed to have habitually unclean patients 
in her department, unless they are afflicted with a fistula, or 
with some other condition of rectum or bladder in which control 
of these parts cannot be acquired. By direct and regular atten- 
tion to uncleanly patients, there are comparatively few cases 
where the habit cannot be broken up, or at least forestalled by 
timely attention in placing them on the commode. 

Before changing the clothing of bed patients, have the clean, 
well-aired clothes at hand. Loosen the nightshirt or gown 
at neck and wrists, bring it and the undervest well up under 
the shoulders on one side of the patient; take out one arm from 
the soiled garments and immediately put on the corresponding 
clean sleeves, slipping both sets of garments over the head, 
thus slipping the soiled ones off and the fresh ones on. Go to 
the other side of the bed, remove the soiled clothing, and put 
on the other sleeves of the clean clothing, pull all down smoothly 
back and front. Bed garments are much more easily put on 
and removed if they are opened all the way down, but it is only 
occasionally that your patients are provided with such, so that 
your efforts have to be directed toward accomplishing the 
changes with as little exertion and as great a degree of comfort 
as possible. 



Chap. VII] THE CAEE OF BED PATIENTS 85 

In paralytics, or patients in which one side is injured, take 
the clothing off the sound side first, and put it on the injured 
side first, as this saves unnecessary movement and pain. Where 
the arm is fractured, the sleeve should be ripped open from the 
wrist to the neck, and tapes sewed on at intervals, to keep the 
sleeve in place. 

Some bed patients need to be carefully supervised to prevent 
and to break up certain bad habits, not only the ones who are 
inclined to urinate or defecate in the bed, but also others who, 
unless watched, are given to using the sheets and pillow slips 
for handkerchiefs and sputum cups; some slyly remove the 
sheets and slips and lie on the ticking; others get between the 
blankets; others hide their heads under the clothes, thus breath- 
ing over and over the air contaminated by their own exhalations ; 
others, because of lack of local cleanliness, together with too 
much lying in bed when such rest is not needed for recuperation, 
develop the habit of self -abuse; and others expend their rest- 
lessness and surplus energy in tumbling or tearing or unravelling 
the bedding. 

These various manifestations need to be studied individually, 
the causes that give rise to them ascertained, and removed as 
far as possible. Idle minds and idle hands are frequent causes 
for these tendencies, and a resourceful nurse will not be long 
b supplying occupation and interests to bed patients whose 
condition admits of their engaging in them. 

Bed pans and urinals should be scrupulously clean, they 
should be thoroughly dry and warm before use, and care should 
be taken, especially if there is any tendency to bed sores, to 
avoid rubbing or dragging the pan against the sacral region 
during its placing or its withdrawal. Request the patient, if 
she will cooperate with you, to raise her hips a little, put your 
hand under her sacrum and slip under the pan. In this way 
the pan comes in contact with your hand instead of the patient's 
back. In removing it, raise her hips slightly with your hand 
and slip out the pan. Very heavy and helpless patients may 
need to be lifted by two persons to avoid mjury to the skin 
from rubbing or dragging. Patients afflicted with involuntary 
evacuations are made more comfortable, and mattress and bed 



86 NURSING THE INSANE [Chap. VII 

linen saved, by the use of a rubber protective pad which, when 
inflated and covered with gauze, is placed under the hips. By- 
means of this the bed can be kept dry without frequent moving 
of the patient. 

In conclusion, it is necessary to consider one of the most 
important things concerning the care of bed patients — the 
prevention of bed sores. 

The first means to this end is the keeping of the patient clean 
and thoroughly dry, day and night, and the bed and body linen 
free from crumbs and wrinkles. Too much emphasis cannot 
be placed upon these measures. Keeping the patient well 
nourished is another potent means of prevention, as it is the 
feeble and emaciated, and those of reduced vitality, as a rule, 
who are prone to the formation of bed sores. Still, certain obese 
persons require painstaking care in this particular. Cases in 
which there is some trophic disorder, where the nerve supply 
is injured, may develop bed sores even with the most watchful 
nursing, but be careful how you excuse yourself, even on these 
grounds. I have seen advanced cases of general paresis remain 
free from bed sores to the very end, though emaciation was 
extreme, but such results were only reached by the most diligent 
and intelligent supervision on the part of both the day and the 
night nurses. An indolent and negligent night attendant can, 
of course, undo a great deal that has already been done by the 
day nurse. 

The prominent parts of the body where continued pressure 
comes, unless the position is frequently changed, and the parts 
subjected to friction, are the places where bed sores are likely 
to form — the sacral region, the hips, shoulders, elbows, inner 
surface of knees, the heels, ankles, and ears are the usual seats. 
When the patient's condition admits of it, taking him out of 
bed even for a few minutes daily, and propping him up in the 
sitting posture, will temporarily relieve the parts upon which 
the weight continually falls. Prevention is like the proverbial 
stitch in time here; it is often exceedingly difficult to heal bed 
sores when once they are formed, but comparatively easy to 
guard against their formation. 

Patients may sometimes speak of a prickling in the parts, or 



Chap. VII] THE CARE OF BED PATIENTS 87 

other sensations of discomfort, but as a rule the danger signal, 
the reddened spot, is the first intimation you have of trouble 
brewing. It is the nurse's duty immediately to report to the 
physicians any suspicious redness of these susceptible parts. 
This rule is too often disregarded, and the first announcement 
made to the physician is that a bed sore has developed in a 
certain patient, the implication being that it just appeared. 
Now a nurse should be ashamed to make such a statement; 
bed sores are not like mushrooms that spring up in a single 
night. The nurse ought to know that it proves that she has 
either deliberately concealed its progressive stages, or that she 
has been lacking in the necessary daily care and scrutiny, and so 
has actually discovered it thus late herself, because of her own 
carelessness. 

Prevention, then, consists first in breaking up uncleanly habits 
if possible; secondly, in cleansing and drying the patient just as 
often, day and night, as he is soiled, however often that may 
be; thirdly, in keeping his skin free from irritation by crumbs 
and wrinkles; and fourthly, in relieving the dependent and 
adjacent parts from pressure by frequent changes of position. 
Here is where cotton pads, cotton and rubber rings, cushions, 
heel pads, ear protectors, and, in serious cases, water and air 
beds, come into play. 

Every sickness that bids fair to be a long one demands at- 
tention in this respect, before any warning signs appear. The 
skin over these susceptible parts should be hardened by bath- 
ing several times daily in dilute alcohol, or equal parts of alcohol 
and camphor, brandy, salted whisky, cologne, vinegar, or lemon 
juice, and the skin kept nourished by inunctions of cocoa butter. 
The parts subjected most frequently to moisture, after being 
thoroughly dried, should be well dusted with toilet powder, 
cornstarch, boracic acid, lycopodium powder, bismuth, or oxide 
of zinc. 

If redness has actually appeared, the physician may order the 
skin painted with nitrate of silver, or if abrasions have already 
occurred, it may be protected by painting over with white of 
egg, with a coating of collodion, with a thin dressing of ab- 
sorbent cotton held in place by collodion, or it may be painted 



88 NURSING THE INSANE [Chap. VII 

with picric acid, dressed with aristol, or any other application 
that the physician may direct, sprinkled on absorbent cotton 
and held in place by collodion, or by adhesive straps. These 
latter, however, are very unsatisfactory, as they not only easily 
become uncleanly, but also irritate the surrounding skin, be- 
sides being painful and difficult to remove. Castor oil and bis- 
muth are sometimes used. 

When the bed sore has actually formed, its treatment is 
outlined by the physician. Various measures are adopted, 
depending upon the extent, severity, location of the sores, and 
the condition of the patient, as well as upon the views of the 
different physicians, and the customs of the various institutions 
in which the patients are treated. 

Whatever local measures are adopted, use them according 
to directions, but never forget that the frequent shifting of the 
patient's position, the removal of pressure from the dependent 
parts, and the prevention of friction are absolutely essential 
to improvement. Patients are often too weak to stay on their 
sides when placed there; pillows and pads well tucked in to 
support them, and soft pads of cotton hollowed out in the center 
and loosely held in place by gauze bandages at knees and ankles, 
may help reduce pressure, and thus promote healing. 



CHAPTER VIII 

BATHING AND HYDROTHERAPY 

The uses of baths are many and varied. In health we bathe 
to refresh ourselves, to keep clean (and, when necessary, to 
get clean), and to promote the free action of the skin. In 
disease we use baths for the above purposes and for therapeutic 
purposes as well — in other words, as remedial agents. Among 
the latter uses may be mentioned the reduction of fever and of 
inflammation, the inducing of free perspiration, and the modi- 
fication of the circulation of the blood. 

Patients in bed should have their faces and hands washed 
and hair combed before breakfast, and again before settling 
down for the night. They should also have a daily sponge 
bath, unless other baths are ordered. Necessary as this is in 
health, it is particularly so in disease. A bath should not be 
given within two hours of a full meal. 

In bathing a bed patient, place her between bath blankets so 
as not to dampen the bed. The room should be warm and every- 
thing in readiness before the bath is begun. Have the clean 
clothing and bed linen, the wash cloth, soap, towels, wash 
basin, pitchers of hot and cold water, and the slop jar close 
at hand. Use a flannel wash cloth by preference, and be gener- 
ous with your towels, discarding any that become damp. Have 
a care to change the water frequently, keeping it warm and 
clean throughout the bath. It is important that the patient 
shall not be chilled or fatigued by the bath. 

When all is in readiness, remove the patient's clothing, letting 
her lie between the blankets, and of course bathe her under 
cover, or at the most expose only a part at a time. A few 
drops of ammonia, or a little borax, may be added to the bath 
water after washing the face, if the body is much soiled, or 



90 NURSING THE INSANE [Chap. YIII 

if the odor of perspiration is strong. Alcohol, benzoin, and 
mildly scented toilet waters are refreshing when added to the 
bath water, and, as a rule, are not objectionable. 

Pay especial attention to getting the corners of the eyes and 
the ears clean, clear the nostrils of patients unable to do this 
for themselves, and brush their teeth, or see that they do it. 
Give careful attention to the paring and cleaning of the finger 
and toe nails, which should be regularly pared at least once 
a week. 

Bathe the face, ears, and neck first, drying each part thoroughly 
as soon as it is bathed. Have an abundance of water, use soap 
generously, especially in the axillae and on the genitals, rinsing 
carefully, and drying thoroughly. Especial attention should 
be given to cleansing the umbilicus, to the folds under the breasts 
and abdomen of fleshy persons, to careful cleansing of vulva 
and anus, and also to the genitals in male patients, and to 
washing and drying carefully between the toes; also the palms 
and between the fingers of patients having contractures and 
habitually closed hands, dusting these parts with toilet powder 
after thoroughly drying them. 

After the face, neck, and arms, bathe the chest and abdomen, 
drying each part as you go along, then the legs and back, lastly 
the genitals. Patients who can be trusted to bathe the genitals 
themselves, may be allowed to do so, but be sure that they 
can be trusted to do it thoroughly. Comparatively few women, 
even among the sane, realize the importance of careful attention 
to this part of their toilet, and need to be taught that these 
parts require daily attention even more than do the face and 
hands. Take especial pains to cleanse the clitoris, and watch 
your masturbation cases to see that no irritation from unclean- 
liness is giving rise to this habit. Patients who are menstruat- 
ing need to have the external genitals bathed with soap and 
warm water twice daily. Tell them that with thorough drying 
there is no possibility of their taking cold, if you find them 
objecting to this hygienic care. 

In bathing feeble patients with sluggish circulations, especially 
in cold weather, it is a very good plan to have at hand plenty of 
hot towels to dry them with, rubbing the limbs vigorously and 



Chap. VIII] BATHING AND HYDKOTHEBAPY 91 

toward the heart. Give a glass of hot milk immediately after 
the bath, and place a hot- water bag at the feet if they are cold. 

If a feeble patient is ordered a tub bath, wrap her in a sheet, 
lowering her in it gently into the water; on removing her, 
roll the body in a dry, warm sheet and blanket, letting her lie 
thus instead of subjecting her to the immediate process of 
drying. After perhaps ten minutes, dry quickly and gently 
with a towel. 

Many of your patients are strong enough to go to the bath- 
rooms for sprays, showers, or tub baths. In these journeys 
to and fro, see that the patient's feet are protected by slippers, 
the body by a sheet, kimono, blanket, or bath robe, according 
to the weather, and the conveniences provided; see that clean 
clothing is near at hand, warmed and ready as soon as the 
patient is thoroughly dried. Do not wait till she is ready for 
it before getting it ready. 

In tub baths for cleanliness, the same attention to details 
noted in the sponge bath should be observed. In the tub, 
always take pains to keep weak patients from slipping, or getting 
startled in any way, resistive ones from getting injured, and all 
patients from getting burned either by the skin touching the 
hot-water faucet, or by a stream of hot water touching any part. 
All depressed patients must be the object of special and con- 
tinual surveillance, lest even attempts at suicide occur. 

Take especial pains in washing the hair not to let soapy water 
trickle into the eyes. Do not leave a feeble or demented patient 
alone in the tub for an instant, nor an epileptic, a general paretic, 
nor one whom you have reason to suspect of being suicidal. 
Do not leave any insane patient alone in the bathroom unless 
you have had specific instructions from the physicians so to do. 
Do not leave the bathrooms unlocked, and thus accessible to 
insane patients, unless a trusty attendant is continually at hand. 

Help weak and aged patients in and out of the tub, whether 
they think they are able to help themselves or not, and aid them 
in drying their bodies and in dressing, taking pains to see if they 
react properly after the dressing is completed. 

In all administrations of baths to the insane, it is of the ut- 
most importance that you so tactfully and skillfully deal with 



92 



NURSING THE INSANE 



[Chap. VIII 



your charges that they look forward to their baths with pleasure. 
As has been emphasized in another chapter, the manner of 
giving the bath, especially the first bath, has a great deal to do 
with the patient's attitude to this important part of the care 
and treatment. Never count time lost that is spent in patiently 
and tactfully attempting to conciliate a patient who shows a 
tendency to fear or resistance in regard to the bath. 

Baths for remedial purposes are very different from those for 
cleansing purposes, and in order to be intelligently applied, the 
nurse needs to know what effects may be expected from the 
various measures adopted; what effect is hoped for in a given 
case; what are the signs that indicate danger; what to do in 
such conditions; and how to administer the various hydriatric 
measures with the best results. 

Baths are general and local, continuous, graduated, medicated, 
of water in varying temperatures, of hot air, and of vapor; 
then there are electric-light baths, sun baths, and mud baths — 
all of which are prescribed according to the object to be attained. 

The generally accepted temperatures for baths are as follows: — 



Cold . 


33° to 65° F 


Cool 


65° to 75° F 


Temperate 


75° to 85° F 


Tepid . 


85° to 92° F 


Warm . 


92° to 98° F 


Hot 


98° to 112° F 



Bath thermometers should be conscientiously used, and the 
bath kept within the limits prescribed. In testing the tem- 
perature of the bath water, first mix the water well with the arm 
or with a long wooden stick, then dip the thermometer into it, 
wait till the mercury ceases to rise, then read the temperature 
while the bulb is still under water. If the bath thermometers 
are fitted with cork so as to float upright in the water, so much 
the better. 

The effects of cold baths are briefly as follows : first, chilliness 
and depression, then quickened pulse, but lowering of tem- 
perature as the blood is driven from the surface to the internal 



Chap. VIII] BATHING AKD HYDROTHERAPY 93 

organs. Reaction, if it takes place as it should, soon shows in 
increased circulation, followed by a warm glow and by a feeling 
of exhilaration. The entire process should last about five min- 
utes. A protracted cold bath results in a return of the chilliness 
and depression and a weakened pulse; this result should not 
be allowed to take place. As a rule, enfeebled persons cannot 
react well to cold baths, at least to cold plunges, and have to 
begin with a plunge in tepid water, gradually lowering the 
temperature by adding cold water or ice. Many who cannot 
stand these measures derive most excellent tonic effects from 
cold sponging, especially if they take the precaution to stand 
with their feet in warm water during the sponging. 

Cool or Tepid Sponging. — This bath is given in feverish con- 
ditions for the purpose of reducing the temperature and sooth- 
ing the restlessness attendant upon fever. 

Water alone, tepid or cold, as ordered, may be used, or alcohol 
may be plentifully used in the water, or alcohol alone may be 
used. (In some cases hot sponging, with vinegar added to the 
water, is ordered, in which case the mode of procedure is about 
the same as for cold sponging.) The sponging is in the main 
done in much the same way that the sponge bath for clean- 
liness is carried out. Everything must be in readiness at the 
start — pillow protector, bath blankets, towels, water, ice, alco- 
hol, two basins, two sponges, and the drinking water. 

Omit the scrubbing and other details necessary when the 
toilet of the patient is being made. Place the nude patient on 
the bed between the bath blankets. Put an ice bag or a cold 
compress on the head and a hot-water bag to the feet, and give 
cold water to drink frequently during the bath. Sponge the face 
and neck with several light, slow strokes, changing the sponge 
every third or fourth stroke, and sponging each part three or 
four strokes before going to the next. Sponge arms, chest, 
and abdomen slowly and lightly from above downward without 
friction. If the fever is very high, after sponging face, arms, 
chest, and abdomen, before going to the legs, wring a towel 
out of cold water and spread it on the chest and abdomen, 
tucking it well in at the sides, so that it will stay in place when 
you turn the patient on the side to sponge the back. Sponge 



94 NUKSING THE INSANE [Chap. VIH 

the thighs, legs, and feet somewhat less than chest, abdomen, and 
back. Support the patient with one hand while sponging the 
back with the other. In sponging for the reduction of tem- 
perature, exposing the parts to the air assists the process, and 
wrapping the patient up in a blanket, instead of drying with 
a towel, is not only less fatiguing, but also aids in lowering the 
temperature. This bath should take about twenty minutes. 
The rectal temperature should then be taken, and instructions 
followed as to how often the bath should be repeated. If it is 
to be repeated often, it is better to leave the patient wrapped 
loosely in the blanket between times, but if not, place the patient 
on the back and put on a long gown opened all the way down 
the back, and simply tucked close to the body at the sides, but 
not buttoned, thus avoiding unnecessary moving of the patient. 

In sponge baths for the purpose of reducing temperature, 
extra pains needs to be taken not to fatigue the patient; do 
not let him help; support each part yourself, gently turn him 
when necessary, but do this as little as possible. Although the 
procedure should be done rapidly and deftly, it should have no 
appearance of haste or confusion. The temperature of the water 
can be kept at 65° F. by adding lumps of ice when necessary. 

In sponging for the night sweats of phthisis, the chief variation 
in the technique is to sponge quickly instead of slowly, and dress 
the patient in a fresh, well-aired nightgown, a complete change 
of bed linen having been effected before the blankets were put 
in place. 

Ablution. — This measure is useful in mild febrile conditions, 
and is also valuable as a tonic and refreshing agent in neurasthenic 
cases, as well as in anemia, chlorosis, and phthisis. Its chief 
value consists in the shock it gives to the peripheral nerves and 
blood vessels, followed by stimulation and a feeling of invigora- 
tion. The breathing and the circulation are quickened, and the 
beneficial effects are seen later in the entire system. 

Have several vessels with water at varying temperature within 
reach. Put the rubber sheet and blanket on one side of the 
mattress. Spread over these a linen sheet, fastening it under 
them on the edge toward the center of the bed, letting one half 
of the sheet reach over the edge of the bed. Place the nude 



Chap. VIII] BATHING AND HYDROTHERAPY 95 

patient on the sheet. Bathe the face (65 to 50° F.), beginning 
with the higher temperature, and reduce two degrees at each 
application. Dash cold water from the hollow of the hand, or 
from a crumpled gauze wash cloth, upon the chest, then upon 
the arms as far as the elbows, the back, abdomen, thighs, gently- 
rubbing each part after applying the water, frequently dipping 
the cloth and squeezing the water over the parts. Dry the 
body by friction with coarse towels, or, if ordered, wrap in a 
dry sheet in readiness on the other side of the bed, and allow 
the patient to dry in that way. Avoid chilling. 

General Ablution. — The patient stands in twelve inches of 
water (95° to 100° F.). Wash the body downward rapidly 
with the hands, having water (50° to 80° F.) poured over the 
patient from a pitcher, followed by gentle friction. Lower 
the temperature each day till he becomes accustomed to the 
lowest. Explain to the patient the importance of the shock 
of cold water to increase the respiration and circulation and to 
tone up the system. Dry by vigorous rubbing. 

The Half Bath. — The half bath is more intense in its effects 
than the ablution. Its chief use is in chronic conditions, and 
to restore tone after wet packs and other measures have pro- 
duced dilatation of the cutaneous vessels. The temperature 
then should be from 90° to 85° F. Its duration should be 
from six to ten minutes. The greatest value of this bath lies 
in the effect produced by the mechanical application of water, 
in successive shocks, and by the friction, which is more easily 
performed since only the pelvis and limbs are under water. 

Put a cold turban on the head. Place the patient in the bath 
tub containing water enough to cover the hips and legs (85° 
to 70° F., or after a wet pack 85° to 90° F.). Bathe the face, 
then rub the back with the left hand while dashing water from 
a small, long-handled dipper over the shoulders; the patient 
meanwhile, if able, rubs his chest and abdomen with both hands. 
Add cold water from the other vessels till the patient shivers. 
Remove the patient if the teeth chatter. Wrap him in a coarse, 
warm sheet and dry rapidly with it. Dry feeble patients in bed 
on a blanket and warm sheet. If the patient is too weak to 
sit up, have him lie in the bath tub and rub him under water. 



96 NURSING THE INSANE [Chap. VIII 

Affusion. — Affusion is still more energetic treatment than the 
ablution. The entire process should be of very short duration, 
and extreme tact should be used with nervous patients to let 
them understand the beneficial effects of what seem like heroic 
measures to them. On no account is the patient to be allowed to 
feel that this bath or any other hydriatric measure is given 
in any sense as discipline or punishment, but only as a means 
of treatment. It is better that a physician be present the first 
time that affusion is prescribed for a given case, and also that 
one be present in every case where the patient is in a critical 
condition. 

Affusions are efficacious by reason of the sudden force of the 
volume of water striking a large surface of the body at once, 
producing a mechanical as well as a thermic influence, benefit- 
ing the entire economy through the quickened respiration and 
circulation, the improved nutrition, and the invigorated nervous 
system. Unconscious and delirious patients, cases in which 
there is cyanosis and threatening heart failure, cases where the 
bronchi are loaded with mucus, are speedily helped by properly 
administered affusions. It often requires courage to adopt 
such measures, but a few trials will convince one of the efficacy 
of affusions in such conditions. 

The patient sits or stands in the empty tub or lies on a rubber 
cot. Pour upon the head, shoulders, and body a stream of water 
(65° to 50° F.) from a pail or a pitcher held at a short distance 
above him, the distance gradually increasing. Do all this rapidly. 
Dry the patient with a warm sheet wrapped around him. 

Place feeble and delirious patients in a semi-recumbent position 
in the water at 100° F. Douche the upper part of the body 
with water from 50° to 65° F. Dry rapidly, as above. 

The Sheet Bath. — The sheet bath is used in acute conditions 
to reduce the temperature in cases where the patient's con- 
dition does not admit of the full bath, and in chronic conditions 
for its invigorating effects upon the nervous system. The first 
effect of the cold sheet is to shock the patient; he will gasp 
and shiver, but if he has a high temperature, his own heat will 
cause this shivering to disappear, and in chronic conditions 
the manipulations of the nurse will overcome the unpleasant 



Chap. VIII] BATHING AND HYDROTHERAPY 97 

symptoms. Chattering of the teeth shows that the* measures 
are proving too extreme for a given case. 

Protect the bed or cot with a rubber sheet, then spread over 
it a blanket. Have in readiness several sheets, preferably linen, 
a basin, a tub of water of the required temperature, a cup, and 
a sponge. 

Wrap the nude patient in a blanket, bathe face and head in 
cold water, fasten an iced turban on the head. Another attend- 
ant drops one sheet lengthwise into the tub of water (50° to 
80° F. as ordered), holding it so that he can easily remove it. 
Wring out the sheet. Spread it on the bed rapidly so as to 
maintain the required temperature. Quickly lay the nude 
patient on the wet sheet with the arms above the head. Bring 
the upper left border of the sheet close under the left axilla, 
and lay across the front of the chest. Tuck the lower portion 
between the lower extremities. Lower the arms to the sides. 
Carry the right portion of the sheet across the body above and 
below, covering the shoulders, arms, and lower extremities. 
Sweep with outstretched hands firmly over the entire body till 
it warms up. As soon as any part is warmed, pour water (50° 
to 60° F.) over it from the cup, and resume the rubbing. Alter- 
nate these frictions and pourings till the whole body feels cool 
and the patient shivers, but stop short of chattering of the teeth. 
Retain the wet sheet. Cover the patient with blanket and 
rubber sheet for one half hour. Do not disturb him if he sleeps. 
Dry with friction and a warm sheet or towels. 

The Drip Sheet. — The drip sheet differs but little from the 
sheet bath except that it is more energetic and more suitable 
for chronic and able-bodied cases than is the sheet bath. It 
is given in the standing position, which admits of vigorous 
friction. This is the thing to be desired in this bath, rather 
than the reduction qf temperature. It has been found especially 
efficacious in chlorosis and anemia ; in the psychoneuroses, such 
as neurasthenia, hysteria, psychasthenia; in melancholia, and 
in pulmonary and bronchial troubles. 

When tonic effects are sought, from two to five minutes are 
sufficient, but when the aim is to lower the temperature, fifteen 
to twenty minutes are needed. 



98 NURSING THE INSANE [Chap. VIII 

The able-bodied patient stands in a foot or bath tub in twelve 
inches of water (100° F.). Dip a sheet in water at 75°, daily re- 
duced till it can be tolerated at 60° F. Raise the right arm, 
place the dripping sheet under the right arm, lower the arm, 
holding it close to the side. The patient then turns around in 
the tub, thus enveloping himself in the sheet. Tuck the upper 
border around the neck and wrap the lower border around the 
legs. Make rapid passes over the sheet up and down the back, 
sides, and lower extremities, with outstretched hands, occa- 
sionally slapping the surface. Pour a basin of water, ten to 
fifteen degrees lower than that the sheet was dipped in, over the 
head and shoulders two or three times, at short intervals, alter- 
nating with friction for five or ten minutes. Remove the sheet, 
have the patient step out of the tub on to a blanket, and quickly 
dry him with a warm sheet. 

The Cold Rub. — The cold rub is best given in the morning on 
rising. It is particularly useful in anemia and phthisis, and for 
insomnia. The length of time for its application varies with the 
case, and is usually prescribed by the physician. 

Wring a coarse linen sheet out of water at 60° to 75° F., and 
wrap the patient as in the drip sheet. Make vigorous friction 
with rapid passes and energetic and frequent slapping. Drop 
the wet sheet, dry with a warm sheet and towels. Dress the 
patient rapidly, then have him take a glass of hot milk, and, as 
a rule, walk briskly in the air for twenty minutes. 

The Wet Pack (Cold Pack). — The wet pack is another means 
of reducing temperature. It is used for this purpose in fever 
cases, especially where there is delirium, also in hysteria, and in 
other functional nervous conditions, to allay irritation and to 
promote sleep. Other conditions may also call for this measure, 
such as diabetes, rheumatism, gout, anemia, chlorosis, and diges- 
tive disorders; in short, in any condition where we wish to aid 
tissue changes and improve the circulation. 

One needs to be cautious in its use with the aged and feeble, 
especially with those having weak hearts or hardened arteries. 
The effect of the wet pack is stimulating, it causes vasomotor 
contraction, and drives the surface blood to the brain and other 
organs ; consequently an ice bag to the head is necessary and a 



Chap. VIII] BATHING AND HYDROTHERAPY 99 

hot-water bag to the feet. The first effect noted is a shock 
lasting from five to twenty minutes, according to the reactive 
powers of the patient; sometimes the patient gasps and shivers 
and begs to be removed, but as the cutaneous blood vessels begin 
to dilate, a comfortable warmth steals over the body, often in- 
ducing a refreshing sleep. If sleep is the object to be attained, 
leave the patient in the pack until he awakens. In very high 
temperatures the sheet steams, and if the pack be continued too 
long, the cold pack becomes essentially a hot pack. This is 
desirable in some cases, where the elimination of toxins is to be 
attained. The continuation of a pack for three hours may, under 
such circumstances, be prescribed — a matter, however, which is 
for the physician to decide. But when reduction of temperature 
is the object sought, the pack needs to be renewed as often as 
the body warms the sheet. In such cases, beginning the first 
pack with a temperature of 60° to 70° F., as soon as the pack 
becomes warm, a new one is applied two degrees higher, and 
again another and another, each two degrees higher, till about 
five packs have been applied, each one of about ten minutes' 
duration. The last pack, which cools but does not chill the 
patient, should continue about fifteen minutes, followed by a 
rapid ablution of 50° to 60° F. before the patient is dressed. 

In giving a wet pack, remember that its success depends upon 
completely excluding the air from beneath the blanket which 
surrounds the wet sheet. 

Have the patient first empty the bladder. The bed should be 
narrow and accessible on all sides. Cover the mattress and the 
pillow with a long rubber sheet. Spread the bath blanket upon 
the mattress so that it extends two feet beyond the patient's feet, 
the left third hanging over the left edge of the bed. Spread a 
large, preferably a linen, sheet well wrung out of water (60° to 
70° F.) on the blanket. Wrap the patient's head in a cold, wet 
turban before placing him nude upon the bed, well to the right 
side. Put his arms above his head. Draw the right third of 
the sheet across the body from right to left. Tuck the upper 
part in along the left side of the trunk, place the lower part 
between the lower extremities, lower the arms to the sides, bring 
the left overhanging part of the sheet over from left to right, 

LOFC 



100 NURSING THE INSANE [Chap. VIII 

enveloping the arms and the entire body, and tuck its border 
along the right side. Draw the blanket from the left and tuck 
under the right side of the body, and draw the right border of the 
blanket over to the left in the same way, securing firmly under 
the body. Draw the upper corner around the neck and secure 
beneath. Tuck the lower border firmly around and over the 
feet. Cover the patient with several blankets. Continue the 
pack from one half to one hour, as directed. Follow it with a 
half bath, sheet bath, cold ablution (70° to 80° F.), or cold 
spray, as ordered. This is necessary in order to restore the tone 
to the relaxed cutaneous vessels. 

The Full Bath. — A Full Bath means a complete submersion 
of the body in water, the water touching the chin, the head only 
being uncovered. There are three kinds : — 

The Cold Full Bath, 

The Warm Full Bath, and 

The Hammock or Continuous Bath. 

In order to apply these properly, a portable bath tub is desir- 
able, though not always obtainable. 

The Cold Full Bath is used more particularly in typhoid fever 
and other infectious fevers, and is what is known as the Brand 
Method. It is dreaded by the laity and by many physicians 
because of its heroic character, but if properly applied, its bene- 
ficial effects soon convince the timid of its efficacy. Chafing 
of the body during the bath is the important thing to insure its 
success. The patient almost always gasps and shudders and cries 
out, and, if strong enough, tries to escape. Try to use calm, 
kindly persuasion instead of force or argument. Tell him the 
unpleasant effects are only momentary. 

We need to remember in choosing which bath should be used 
that " the rapid application of a low temperature is more refresh- 
ing and stimulating, though not more heat-reducing, than the 
prolonged application of a bath of higher temperature.' ' 

Chilliness, blueness of the hands, and even a small pulse are 
not sufficient indications for discontinuance of a bath, but chat- 
tering of the teeth and blueness of the face are. These latter 
manifestations are not likely to occur if the friction and chafing 



Chap. VIII] BATHING AND HYDROTHERAPY 101 

are properly kept up, and the water is kept in motion. Redness 
of the skin which was at first pale shows that the chafing is having 
the desired effect. After removal from this bath, the restless 
patient usually sleeps. Prolonged shivering shows that the bath 
has not yielded the desired results, owing to some defect in its du- 
ration, in the temperature, or in the technique. Subsequent baths 
should then be of shorter duration and of higher temperature, 
to conform to the patient's feeble reactive powers. If the cold 
bath has had the desired effect in fever patients, the pulse, 
though small, and even almost threadlike, will be found to have 
gained in force and tension, and it will continue to gain. 

Graduated Baths are similar to the Brand bath about to be 
described, with the exception that, instead of putting the patient 
in the lowest temperature at the start, he is put in water from 
90° to 86° F., and cold gradually added, while the warm water 
is removed. While more agreeable to the patient, this bath is 
harder to apply, more fatiguing in the long run, and less effica- 
cious as well. 

In all baths where the temperature is modified after the patient 
is in the bath, take great care that neither the hot nor the cold 
water is added so that it comes intimately in contact with the 
body. If ice is added, let it be done quietly, by lowering it into 
the water in a towel, and thus moving it back and forth in the 
tub so that the patient does not see it. 

The Cold Full Bath is administered as follows : Give the pa- 
tient a glass of hot milk (with stimulant, if ordered). Undress 
him and place a diaper around the loins, and a narrow, dry, hand- 
kerchief bandage around the head, with a knot at the nape of the 
neck, to form a gutter for the water to run off. Bathe the face 
in cold water. Have the patient step (or if feeble, lift him) into 
the bath, previously drawn, the water at a temperature of 90° 
to 65° F., as ordered, two persons gently lowering him into the 
water, which should come up to his chin. Reassure him as he 
gasps and tries to escape, by kindness, firmness, and encourage- 
ment. Support his head with your hand, or let it rest upon the 
head strap or air cushion. A water cushion ring for the but- 
tocks adds to his comfort and support. Practice unremitting 
gentle friction or chafing over successive parts of the body ex- 



102 NURSING THE INSANE [Chap. VIII 

cept the lower abdomen. Chattering of the teeth is always a sign 
for removal, also blueness of the face, but not necessarily of the 
hands. Several times during the bath gently pour a basin of 
water at 50° F. over the head, taking care not to let it run down 
the face. The time occupied should be from ten to fifteen min- 
utes. Lift the patient out, drop the loin covering, and place the 
patient upon the bed which has been previously prepared as 
follows : A double blanket spread on one side of the bed, a pillow 
covered by a towel and placed under the blanket. Spread a 
sheet, preferably linen, upon the blanket. Place two hot-water 
bags at the feet. Lay the patient upon the sheet, bring it 
around him, pressing the folds between the arms and the chest 
and between the lower extremities, so that no wet surfaces of 
the body touch each other. Wrap the blanket around him. If 
the temperature is above 103° (rectal), let the patient remain 
in the sheet ten or fifteen minutes. If lower, dry at once with 
a sheet and towels. 

The Warm Full Bath (90° to 100° F.) is chiefly of use in reduc- 
ing temperature, especially in children, in allaying nervous irrita- 
tion, and so acting as a sedative in insomnia, and in lessening 
pain. 

The technique of the warm full bath is as follows : Fill the tub 
full of water at 98° to 100° F., adding hot water from time to 
time to maintain the desired temperature. Keep the patient 
immersed up to the chin. Do not employ friction. Let the 
patient's head rest upon the head strap or support it. Continue 
the bath twenty-five to thirty minutes or longer, as ordered. Dry 
the patient between cotton sheets. Place a hot-water bag to the 
feet if necessary. If higher temperatures are used, place cold 
turbans around the head during and after the bath. 

Hot Baths are given to induce free perspiration, especially in 
cases where the kidneys are not acting freely. They are given 
in convulsions of children, for influenza, for insomnia, and many 
other conditions. 

A prolonged hot bath raises the temperature, causes palpita- 
tion of the heart, a full pulse, superficial breathing, vertigo, 
nausea, and collapse. Frequent hot baths cause reduction in 
weight. Very hot baths (110° F.) after marked muscular exer- 



Chap. VIII] BATHING AND HYDROTHERAPY 103 

tion remove fatigue. In dysmenorrhea, hot half-baths (100° to 
110° F.) for twenty minutes frequently afford great relief. In 
cases of bronchitis, nephritis, and rheumatism, hot baths are 
often very useful. Patients with hardened arteries and cases of 
angina pectoris should not take hot baths. 

It is of the utmost importance that all details be prearranged, 
so that no delays and no thwarting of the object to be attained 
can occur. 

Fill the portable tub half full of water at 100° F., and draw it 
to the bedside. (If a portable tub is not obtainable, have plenty 
of warm blankets ready to cover the patient so that transition 
from bath to bed does not interfere with the effects desired.) 
Put the patient in- the tub, and gradually increase the tempera- 
ture of the water until the thermometer registers 110° F. Keep 
a cold turban or an ice bag on the head during the bath, and 
watch the. pulse. If the patient shows sign of faintness, remove 
him immediately to the bed. Unless otherwise ordered, if all 
goes well, maintain this temperature from ten to fifteen minutes, 
then lift the patient into the bed, which has previously been 
protected by a rubber sheet. Wrap him in three or four hot 
blankets, tucking them closely about the neck and feet so as to 
prevent the access of air. Give copious draughts of water. Keep 
up the sweating for an hour, then gradually unwrap the patient, 
sponge him under a blanket with alcohol and cool water, and 
remove the wet blankets. 

Vapor Baths, Steam, and Hot Air Baths. — Vapor baths are 
given with special apparatus, or they can be given with one im- 
provised for the purpose. 

If the patient is able to sit up, the vapor bath can be best 
administered that way, otherwise it can be given in bed. A 
cane-bottomed chair is used. In the sitting position, the nude 
patient is covered in on the chair with a blanket which is fastened 
closely around his neck and draped about him and the chair to 
the floor, so as to prevent the access of air. Putting the feet in 
a hot foot bath under the blanket increases the effect. For the 
hot-air bath an alcohol lamp set in a tin basin underneath the 
chair is then lighted, and the patient kept in that position till 
he perspires freely, cool drinks being given meanwhile, and a cold 



104 NURSING THE INSANE [Chap. VIII 

turban surrounding the head. Or, if a vapor is desired, a kettle 
of boiling water may be placed under the chair. 

If the bath is given in bed, protect the bed with a rubber sheet 
over which a blanket is spread, and upon that place the nude 
patient, having him lie on one side. Arrange bed cradles with 
barrel hoops which extend from one side of the bed to the other, 
if no regular bed cradles are at hand. These support the blan- 
kets and the rubber sheet which are to cover the patient's body 
and exclude the air. Leave a small opening at the foot of the 
bed (unless the bed has a high footboard, in which case the 
opening will have to be made on the side well toward the foot) 
where the spout of the teakettle, or better still, a funnel-shaped, 
long tin spout, which is attached to the spout of the teakettle of 
boiling water, is introduced. The kettle is to be placed upon a 
chair or stool at the foot of the bed. It is kept boiling by a gas, 
oil, or alcohol stove or lamp. If the water becomes exhausted 
in the kettle, it must be replaced by boiling water so as not to 
have the supply of steam interrupted during the procedure. 

Take pains that the blankets are tightly fitted around the fun- 
nel so that no cool air reaches the patient. The vapor or hot 
air should enter on a plane above the patient. 

In giving this bath to the insane, and, in fact, in all cases, 
constant watchfulness needs to be exercised not to burn the 
patient by allowing the hot funnel to slip and touch the body, 
not to let the blankets become ignited from the flames of the 
lamp, nor to let the lamp or water be upset. 

The bath may be continued from one half to one hour, or until 
free perspiration is secured. The pulse should be taken at the 
temples, thus avoiding uncovering the patient. At the end of 
the bath, sponge the patient as after a hot bath. 

The Continuous or Hammock Bath requires a special bath tub, 
or at least a special apparatus for an ordinary bath tub, so that 
the patient may lie comfortably under water, but supported by a 
sheet or a frame, as in a hammock. He needs to be made thor- 
oughly comfortable, and may be kept in the bath from two hours 
to all day and night, or even for weel^s, only removing him to 
anoint his skin twice a day or to let him empty the rectum and 
bladder when necessary. 



Chap. VIII] BATHING AND HYDROTHERAPY 105 

The sense of chilliness first experienced upon getting into the 
bath soon subsides and gives way to comfort. The continuous 
bath is especially efficacious for nervous and mental cases where 
there is a great deal of irritation, shown in increased excita- 
bility, in paralyses, in bed sores, in suppurating wounds, and in 
many spinal-cord affections, in articular and muscular rheuma- 
tism, and in chronic diarrhea and cystitis. 

Before applying the continuous bath, anoint the patient's 
skin, except the face, with mutton suet or cocoa butter to pre- 
vent peeling or puckering. Fill the tub with water at 100° F. 
Lay the patient, clad in a shirt or chemise, on the suspended sheet, 
which just clears the tub bottom. A rubber pillow should be 
used. Keep the water near 100° F. by the addition of warm and 
the removal of cooled water. Never allow the temperature of the 
water to fall below 95° F. Cover the tub with a blanket. The 
patient is to be left in the tub for short or long periods, as or- 
dered. If he sleeps, watch that his head does not sink in the 
water. On no account is he to be left unobserved. 

Compresses. — Compresses are local wet packs, and if the 
technique of general packs has been grasped, there should be 
no difficulty in understanding how to apply a head, throat, 
chest, or abdominal compress. In general, cold applications 
help to allay inflammation, and hot applications to hasten sup- 
puration if it is unavoidable. When inflammation in a part is 
superficial, thin compresses are used; they are applied frequently 
and are not covered, but when one wishes to affect the deeper 
tissues, the compress should be thicker, and allowed to remain 
unrenewed longer, acting more as a fomentation as the cold com- 
press becomes heated and steaming from the tissues beneath. 

The throat compress is used in tonsilitis, diphtheria, and for 
tracheal and laryngeal disorders. Unless properly applied, it 
slips away from the parts needing it, and is then worse than 
useless. 

Select a piece of thin old linen long enough to reach below the 
chin from ear to ear, and wide enough to form a pad of four 
thicknesses. Next, take a piece of flannel eight by twenty-four 
inches, and cut slits in it for each ear, fitting the linen and the 
flannel to the patient's head before wetting the compress. Then 



106 NURSING THE INSANE [Chap. VIII 

wring the compress out of water at 60° F. and lay it upon the 
middle of the dry flannel. Place the wet compress under the 
chin and unroll the flannel bandage from the top of the head, 
passing it over the right side of the head ; let the right ear come 
through the slit, pass under the chin to the left side, letting the 
left ear protrude, then draw firmly over the head and fasten with 
a safety pin. Have two sets of bandages, so that one may dry 
while the other is in use. In restless patients, make a circular 
turn around the forehead for greater security. 

The chest compress is used by some physicians in congested 
conditions of the lungs, by others in the later stages of pneu- 
monia only, and in phthisis, when cough and dyspnea are marked. 
Its value in fevers as a means of reducing temperature is great. 

The chest compress is made by folding old linen in three or 
four folds to fit the chest from the clavicles to the navel in front, 
and a corresponding position behind, with slits under the arms 
deep enough to admit of the flaps on each side covering the 
shoulders. Two such jackets should be made, and two pieces 
of thin flannel, somewhat larger, should likewise be fitted to the 
patient. 

Roll up the compress and soak in water 60° F., wring out just 
enough so that it does not drip. Spread out the flannel upon 
a flat surface and put the wet compress upon it. Roll both 
together halfway. Gently turn the patient, whose chest is bared, 
upon his left side, place the compress and flannel on the bed so 
that the rolled part lies close to his left side, and the lower edge 
of the left slit is under the left axilla. Then turn the patient 
gently upon his back so as to release the rolled-up part; unroll 
this, and then bring both edges of the compress forward on the 
front of the chest. The flannel cover which has been lying on 
the bed, under the compress, is then brought over the compress 
and pinned in front and upon the shoulders with safety pins. 

In changing chest compresses (which should be done every 
thirty minutes while the temperature remains above 102° F., 
and every hour while above 99.5° F.), be careful to have the 
second compress ready and rolled before removing the other one, 
so there will be no delay in the procedure. These compresses 
need to be changed night and day unless the patient is asleep. 



Chap. VIII] BATHING AND HYDROTHERAPY 107 

Care must be taken to keep the compresses clean by rinsing them 
thoroughly in clean water before rolling them in the water at 60°. 

Where it is desirable to have the effects of a fomentation, in 
cases of insomnia or other conditions of nervous excitability, the 
temperature of the water may be higher than 60° F., the com- 
press may be left more moist than as before described, and may 
be allowed to remain on two hours or more, as the physician 
directs. 

The abdominal compress is used in typhoid fever, gastritis, 
inflammation of the liver, peritonitis, appendicitis, and in in- 
testinal troubles of children and adults when accompanied by 
fever. It is made of three folds of linen of a size and shape to 
extend from sternum to pubes and lap over on each side of the 
abdomen. This is wrung out of water at 60° to 70° F., and held 
in place by a wider flannel bandage bound around the body and 
pinned in front with safety pins. It is not necessary to remove 
the flannel binder when the compress is removed unless it has 
become dampened. Two sets should be supplied if possible. 
If each compress is boiled once daily, there will be little danger 
of the formation of boils. Protect the bed with an extra 
sheet folded under the trunk. Sometimes, instead of the com- 
press merely covering the abdomen, it is put all around the 
trunk, with a double layer over the abdomen. It is then called 
the Neptune girdle, and when to this girdle is added a rubber 
coil on the abdomen, with hot water circulating through it, it is 
called the Winternitz Combination Compress. This is used in 
cases of obstinate vomiting, and in various gastric conditions, 
also in painful menstruation, peritonitis, and the like. The 
Neptune girdle has been found useful in cases of insomnia. 

The Hot Fomentation Compress consists of two pieces of 
flannel eighteen inches square, saturated in boiling water and 
wrung out by a wringer, or, if none is available, wrung out dry 
in sheets. Anoint the parts to which it is to be applied with 
cocoa butter or olive oil to prevent burning, then wrap the pa- 
tient in a dry blanket pack. Open the blanket enough to slip 
in the fomentation, untwist the sheet, and quickly place the hot 
flannels upon the affected part and close the blanket again. 
The extreme heat, which may be unpleasant, is of very short 



108 NURSING THE INSANE [Chap. VIII 

duration, but your tact will be needed to persuade the patient to 
endure it. If these hot compresses are applied every ten or 
fifteen minutes, after three or four applications one has a vapor 
bath. On discontinuing, gradually unwrap the patient, dry each 
part thoroughly, then quickly sponge off with water at 75° F., 
and after friction and drying, put him in bed. This compress 
is of great value in sciatica, lumbago, intercostal pain, and 
other rheumatic muscular affections. 

The Douche. — The Douche is the application of water, under 
pressure, to a given part, by means of a rubber hose connected 
with the water supply, the nozzle attached to the hose admit- 
ting of coarse or fine jets, or a fan-shaped douche. Then there 
are rain or shower douches, circular douches (needle bath) and 
ascending douches. 

By means of the douche, water may be applied at a lower 
temperature speedily, and the result of stimulation and invigora- 
tion thereby more easily attained than by some of the hydriatric. 
measures previously described. Only certain parts of the body 
receive the water at one time, so that the system is called upon 
to react more gradually than in a cold bath. The disagreeable 
impression is thereby lessened, and in any case it is "all over in 
a minute/' for a cold douche (below 55° F.) should never exceed 
one minute, and should occupy from ten to thirty seconds only 
upon any part. The skin should react by a rosy hue. 

One of the chief uses of the douche is to relieve muscular 
fatigue and to increase the resisting power of the muscles so that 
they are capable of doing better work ; persons of lax fiber, of 
sedentary occupations, are especially benefited by it. In the 
douche the water acts as a kind of massage, only much more 
efficaciously. It improves the circulation, the digestion, and 
the nerve tone. Anemia and chlorosis, neurasthenia and gastric 
ailments are benefited by this treatment. 

Scotch douches are alternating streams of hot and cold water 
rapidly played upon some part. The physician should direct 
the temperature, the duration, and the pressure to be used for 
each case. It is important that enough pressure is used to set 
up a reaction, or chilliness, depression, and muscular pains will 
be likely to follow. 



Chap. VIII] BATHING AND HYDROTHERAPY 109 

Sitz Bath. — In the sitz or hip bath, the patient sits in an 
especially arranged tub of water, so that only the pelvic portion 
of the body is submerged, the water reaching as high as the 
navel. The head is enveloped in a turban. Fill the tub half 
full of water at the prescribed temperature. The patient then 
sits in the tub, the legs hang over the edge in a comfortable posi- 
tion, and the feet are supported on a stool if necessary. They 
should be wrapped in a blanket, and a hot-water bag placed 
under them if the patient is chilly. Add more water of the 
required temperature, pouring it in rapidly without its touching 
the patient, while he keeps up active friction on the abdomen 
and the thighs, an attendant meanwhile keeping up friction in 
the lumbar regions and sides. As a rule, the temperature for hip 
baths is from 50° to 60° F., and their duration ten to twenty 
minutes. 

In obstinate diarrhea cold hip baths are often used, pre- 
ceded by energetic wet-sheet rubbing. For prolonged and pro- 
fuse menstruation they are prescribed at 85° F., to last from five 
to eight minutes, followed by the circular bath and then by 
douches at the same temperature. They are continued daily 
till the flow ceases. Prolonged cool hip baths are sometimes 
used in diarrhea, dysentery, cystitis, and uterine hemorrhage. 
Prolonged warm hip baths (95° to 100° F.) are beneficial in cer- 
tain forms of dysmenorrhea. A temperature of 70° to 80° F., 
with friction, is used in chronic uterine and vaginal derangements. 
Brief cold hip baths are prescribed for prolapsus of the anus and 
uterus, and for leucorrhea and constipation; prolonged cold 
hip baths for hemorrhages of any of the pelvic organs, especially 
for hemorrhoids. 

Irrigation. — By irrigation is meant the application of water 
upon surfaces or in cavities. We speak of irrigation of the 
stomach as lavage. In infants this is sometimes necessary in 
obstinate disorders of the stomach and intestines. Whenever it 
is necessary to resort to this procedure, see that nervous and 
unduly impressionable persons are excluded from the room. 

Put a quart of water (95° to 100° F.) in which a teaspoonful of 
salt or of bicarbonate of soda is dissolved in a fountain syringe. 
Connect the syringe tube by means of a small piece of glass 



110 NUKSING THE INSANE [Chap. VIII 

tubing to a No. 8 Nelaton or Jacque catheter. Gently but 
firmly press the catheter either through the pharynx or the nose 
into the child's stomach, the child being held upright by another 
person. Sometimes the child gets cyanotic, but if the catheter 
is in the esophagus and not in the air passage, this is of no con- 
sequence, though rather distressing to witness. You should 
introduce the catheter before connecting the syringe. When 
the child vomits the water, disconnect the catheter and allow 
the stomach debris to pass out, holding the tube near the mouth 
to prevent its being displaced. When done, pinch the catheter 
and withdraw rapidly, holding over the basin and letting go to 
let the contents of the tube escape into the basin. 

Lavage for Adults. — Place the patient upright in a chair with 
the head thrown back, and the clothing protected by a rubber 
sheet. Place another chair in front of him. Select a large, firm, 
but soft rubber stomach tube. Have two to six quarts of water 
ready. Place a basin in the chair in front of the patient. Re- 
move artificial teeth. Stand on the right of the patient, dip the 
lower end of the tube in warm water, hold it like a pen, introduce 
it over the tongue, trying not to touch the tongue. When the 
tube strikes the back of the pharynx, tell the patient to swallow 
and bend the head forward. Gagging may take place, but reas- 
sure the patient; in fact, tell him beforehand of the liability of 
gagging and vomiting, and that he must keep the mouth open. 
If the tube meets with obstruction at the cardiac orifice, pouring 
warm water into the funnel will relax the spasm, and the tube 
will pass down. You may have to move the introduced portion 
back and forth, but avoid this if possible, as it causes gagging. 
When the tube is introduced to the line mark, have an assistant 
hold it near the teeth, the mouth being kept open. Be sure that 
the tube is not in the trachea before pouring in the water. This 
is poured into the funnel connected with the tube. If the 
patient does vomit, have him lean over the basin and allow the 
vomitus to flow through the tube. After introducing about a 
pint, the funnel is turned down into the basin to form a 
siphon, while the water is still flowing. When the water runs 
free, grasp the tube firmly in front of the teeth and withdraw 
quickly. 



Chap. VIII] BATHING AND HYDROTHERAPY 111 

Irrigation of the Intestines with a large quantity of water by 
means of a long rectal tube is called intestinal irrigation or 
enter ocly sis. The object is usually to distend and cleanse the 
passage, being different from the ordinary small enema of warm 
water (containing soap or other ingredients) which is injected 
by means of a short rectal tube for the purpose of producing an 
immediate evacuation of the bowels. Flushings of the intes- 
tines are also used to stimulate the kidneys to action. In such 
cases the patient should continue to lie down and should retain 
the water, that it may be absorbed. 

Intestinal irrigation is accomplished by means of the largest- 
sized Nelaton catheter, attached to a fountain syringe, con- 
taining one or more quarts of water that has been previously 
boiled and partly cooled. Place the patient upon the back upon 
the protected bed or upon an enema cot, arranging a rubber 
sheet which falls into a tub or receptacle below, acting as a gutter 
for the water as it comes away. Protect the floor round about. 
Anoint the tube, hold it between the thumb and index finger 
and introduce it into the anus, after first allowing the water to 
run off into the waste receptacle until it runs warm. Gently 
but firmly press the tube up into the intestinal canal. If the 
tube meets with an obstruction, withdraw it a little and gently 
insinuate it upward. By allowing the water to flow and distend 
the bowel, the process is often made easier. When the upper 
part has reached the transverse colon, or when it has gone as far 
as it will go, providing it has not become curled on the way, hold 
the tube in place until about two quarts of water have been 
injected. If there is entire stoppage of the flow, or an imme- 
diate return through the anus, you may suspect that the tube is 
doubled in the rectum. The temperature of intestinal irriga- 
tions may vary from cool to hot, the warm or hot being most 
often prescribed, as they produce the best results. 

Irrigation of the Bladder is done by a double-current catheter, 
or by an ordinary catheter, attached to a fountain syringe. The 
temperature of the fluid to be used should be about 110° F. The 
clean catheter, anointed, is slowly introduced. The urine is 
allowed to drain off, after which the water is allowed to flow 
into the bladder until a slight feeling of distension is noted, or 



112 NURSING THE INSANE [Chap. VIII 

until about a quart of water has been introduced. The pro- 
cedure differs in details according to the apparatus used. 

Irrigation of the Vagina is used for cleansing purposes and to 
reduce inflammation. A douche pan and a fountain syringe 
are needed. The patient should lie in the recumbent position. 
The temperature and quantity of water used vary according to 
the results to be sought. The perineum should be anointed 
before introducing the nozzle. 

Foot Bath. — If the patient is able to sit in a chair, the foot 
bath can be given easily in that way, but if not able, have the 
patient lie on the back, bending the knees and placing the feet 
in the foot tub which rests on the bed, having been introduced 
at the foot of the bed by loosening and lifting the clothes at the 
end. The bed should be previously protected with a rubber sheet, 
and care should be taken that the tub is evenly placed, so that it 
will not joggle. If the patient is sitting up, wrap the knees and 
the foot tub in a blanket. 

Foot baths are often prescribed for colds in the head, conges- 
tive headaches, delayed menstruation, and the like, the purpose 
being to bring a freer flow of blood to the extremities and thus 
equalize the circulation. Simple hot foot baths are also used for 
sprains. When mustard is added to the bath, use about one and 
one half teaspoonfuls to one gallon of water, first making a paste 
of the mustard before adding it to the bath. The water should 
come at least halfway up to the knees. The bath may continue 
ten to fifteen minutes, adding water from time to time to keep 
it at the original temperature. After the feet are removed and 
dried, wrap them well in a blanket. 

Medicated Baths are sometimes used — mercury, vinegar, 
bicarbonate of soda, sulphur et of potassium, bran, starch, etc., 
being added to baths as prescribed by the physician. 



CHAPTER IX 

THE PREPARATION AND SERVING OF FOOD 

Next to seeing that patients have food of good quality and in 
sufficient quantity, the nurse needs to attend to its being served 
regularly and invitingly, in the pleasantest surroundings and 
under the most favorable conditions procurable. 

A contented mind and a cheerful disposition go a long way 
toward aiding digestion. Whatever interferes with these, un- 
favorably affects the nutrition. Petulance, anger, envy, hurry, 
worry, remorse — these are all enemies to digestion. How im- 
portant is it, then, that the dining-room attendants and the 
nurses in the hospital departments, where trays are served, make 
it their conscientious care to reduce these unfavorable influences 
to a minimum. In the dining rooms, tactful supervision is neces- 
sary to prevent the beginnings of contentions; in the hospitals, 
care is required to secure as much freedom as possible from dis- 
agreeable sights or odors. The ventilation of the hospitals be- 
fore and at the meal hour is all-important; the doors to the 
water sections should be kept closed; unsightly patients should be 
screened as far as possible; in the tubercular wards, sputum cups 
should be put out of sight for the time being. In the dining 
rooms, patients who are disturbed habitually, or who are disgust- 
ing in their habits, should be reported; permission will often 
be given to serve such patients with trays in their rooms. Care 
should be exercised in seating congenial persons together and in 
separating antagonistic ones. The efficient dining-room attend- 
ant will take pride in making her dining room attractive by atten- 
tion to ventilation and to the regulation of the temperature, by 
admitting plenty of sunlight, by scrupulous order and cleanli- 
ness, by such adornment as she can obtain in the different seasons, 
— wild flowers, grasses, autumn leaves. She will look to the 
i 113 



114 NURSING THE INSANE [Chap. IX 

supply of linen and dishes; will keep the former well mended and 
as fresh as possible at all times; will try to prevent nicks and 
cracks in dishes; will see that they are thoroughly washed, rinsed, 
and dried; will keep the silver and glassware polished, the chairs 
and furniture in good repair; and the supply of napkins always 
adequate, so that a shortage does not occur, occasioned by her 
delay in making out timely requisitions. The same thing holds 
true in regard to the staple supplies — sugar, salt, butter, and 
the like. 

It is the duty of the dining-room attendant to keep the refrig- 
erator clean, to prevent the accumulation of food that would 
vitiate butter or milk. Nothing should be allowed in the heaters 
except the food to be kept hot and the plates, vegetable dishes, 
platters, etc., which are to be put there long enough before 
meals to admit of their being thoroughly heated for the serving 
of hot food. These dishes and the hot food should not be 
removed from the heaters until just before or after the patients 
are seated at the tables, else your efforts at heating them will be 
thrown away. 

Special diets, and also the extra food provided by relatives, 
should be conscientiously served to the patients for whom they 
are intended, and care taken that they are not purloined by dis- 
honest or mischievous persons. 

The dining-room attendant is directly responsible for answer- 
ing the bell of the dumb waiter, for keeping the door to it locked, 
for keeping the knife drawer always locked, except when tak- 
ing things from or putting them into the drawer. She should 
make it a routine matter always to try the lock after turning the 
key. She is to exercise the utmost care in using the carving knife 
and fork and bread knife, not to let any of them out of her hand 
for an instant, except to lock them in the drawer. She may 
make no excuse that the dumb-waiter bell was ringing, or that 
she knew the patients near by were to be trusted, or that she 
left them, thinking some other nurse would watch them. These 
excuses will not be accepted for infringement of this rule. She 
is to keep in the knife drawer a list of all the articles contained in 
it; her list must show the number of knives, forks, and spoons of 
any kind that are in her department. All knives, forks, and spoons 



Chap. IX] PREPARATION AND SERVING OF FOOD 115 

are to be gathered up and counted before the patients leave the 
dining room, and if any are missing, thorough search must be 
made before the patients are allowed to disperse. Failing to 
find the missing article, the fact must be immediately reported 
to the supervisor. 

After the patients are seated at the table, the dining-room 
attendant and those who assist her in the serving of meals should 
extend the most courteous and watchful assistance to the assem- 
bled patients. Patients who are wasteful, and those who are 
greedy and serve themselves too abundantly, should be served 
by the nurses with enough, but only enough; this is not only 
to prevent waste, but to prevent overfeeding. Some patients, 
unless watched, will help themselves to enormous quantities of 
food, while patients who are of retiring dispositions, or who are 
depressed or indifferent, will not take sufficient food even if it 
is there to take, and others cannot if the greedy ones appropriate 
the lion's share. 

Much can be done, by example chiefly, and also by precept, 
to train certain ones who need it to better table manners than 
they voluntarily show. Every dining-room attendant should be 
conversant with the ordinary rules for waiting on table and serv- 
ing food; she should know how to lay the table in the proper 
way; should pass things from left to right, and should have a care 
not to fill cups, glasses, or any dishes to their utmost capacity. 

Patients with dainty or capricious appetites need especial care. 
Do not discourage them by piling too much on their plates ; coax 
them by the daintiness with which you serve their food; if there 
is any choice, select the best dishes for them, dishes without 
nicks or cracks. Remember, if you can, the likes and dislikes of 
the various ones. Certain patients are more susceptible to these 
little things than others, and the discerning nurse will be quick to 
see what ones she needs to cater to especially, always bearing in 
mind, however, that she is not to show what could be construed 
as favoritism to any. Patients with loss of appetite or poor 
appetites should be regularly reported to the charge nurse. If 
you notice that they have poor teeth, call attention to this, and 
take especial pains to select for them suitable food. Watch the 
weight lists from month to month of the patients in your depart- 



116 NURSING THE INSANE [Chap. IX 

ment ; and set about to see what you can do in each case, where an 
undesirable loss of weight is noted, to remedy the condition. 

Food comes to the wards in large quantities in covered tin boxes 
and cans. When cooked in such bulk and so distributed, it can- 
not present an especially tempting appearance. It is the duty 
of the nurse to serve it so that it is as tempting as possible to the 
patients. Do not hurry patients at meals. Remember the im- 
portance of thorough mastication and insalivation and a cheerful 
atmosphere. Do not urge all patients to eat, whether they are 
hungry or not. Sometimes it is well, especially for well-nour- 
ished persons, to go without a meal or two if the appetite is 
wanting. But urge all your patients to chew their food thor- 
oughly, to drink all liquids slowly, and not to wash down their 
food by drinking while they have food in their mouth. On no 
account are patients to be allowed to take food away from the 
table. 

Patients in the hospital departments require food which can 
be easily digested. Liquid nourishment is there used more 
abundantly than solid food. Milk is an almost ideal food to 
supply the tissue waste in these patients. It contains albumen, 
fat, sugar, water, and inorganic salts. If patients cannot take 
it plain, hot milk salted, and perhaps diluted with plain or effer- 
vescent or lime water, or with a little cooking soda, will remove 
the real or fancied difficulty, or peptonized milk may be given. 
Buttermilk, koumys, whey, broths, soups, and meat jellies are 
important articles of diet in these cases; also the white of egg, 
beaten to a froth, strained and mixed with an equal quantity of 
water and flavored with a few drops of lemon juice. 

Punctuality in serving meals to hospital patients is even more 
important than it is to those who go to the dining rooms. The 
nourishment is, in many cases, given oftener than at the regular 
meal hours, and should be served punctually, according to direc- 
tions in individual cases, the nurse in charge keeping a list with 
specific instructions as to the kind of food, the quantity, and fre- 
quency of serving. 

Patients who are given food while in bed should be placed in 
as comfortable a position as possible. Bed trays or bedside 
tables should be used wherever they are to be had, and the trays 



Chap. IX] PREPARATION AND SERVING OF FOOD 117 

and all food and dishes are to be removed as soon as the patients 
have finished with them. Fruit is not to be left in the sick room 
between times, but is to be brought, temptingly prepared, at the 
time it is to be taken. Grapes, oranges, and grape fruit should be 
served cold. Dried fruits, such as raisins, figs, dates, prunes, 
apricots, may be placed in a small dish on the breakfast tray. 
They are important additions to the diet. Food meant to be 
served hot should be hot, food meant to be cold should be cold — 
no lukewarmness in the matter. Monotony is to be avoided, 
both in the kind of food offered and in the method of serving. 

As a rule, do not ask a patient what she would like to have to 
eat. Remember that even a simple surprise will often do wonders 
to whet the appetite. 

As before mentioned, dainty portions beguile patients into eat- 
ing and often into asking for a second helping, where piling up a 
dish, or even a moderate serving, may discourage one. In filling 
cups, glasses, saucers, do not fill to the brim, and always make 
allowances for possible jarring in carrying the trays, so that even 
if this occurs, there shall be no slopping over. If chronic or con- 
valescent patients assist in preparing and carrying the trays, they 
need especial supervision in this respect. If accidents of this 
kind do occur, carry the tray away, empty the dishes thus made 
unsightly by spilling, put on a dry napkin, and then serve the 
tray. The necessary delay is the lesser of the two evils. Never 
taste a patient's food in her presence. Taste the food in the serv- 
ing room and reject or rinse the spoon which you so use. 

If friends of your patients can afford it, and seem eager to 
know what they can do to contribute to the patient's comfort, 
suggest that they send individual trays and napkins, dainty dishes, 
and all the appointments, having a care to consult the patient's 
preferences as to color if they are known. These individual 
touches make your work a little harder, perhaps, but the grati- 
fication the patient so often evinces will go a long way to recom- 
pense you for the extra care. 

Sometimes placing a flower — often a simple wild flower — 
a bit of evergreen, or a bright autumn leaf on the tray, or occa- 
sionally a humorous quotation, or one about something concern- 
ing which you know the patient is especially interested, will add 



118 NURSING THE INSANE [Chap. IX 

a charm it is difficult to estimate unless you have been ill yourself, 
or have otherwise seen the effects of these gracious little atten- 
tions. 

Feeble and helpless patients need to be fed by the nurse, also 
those who are confused, or overactive, or too depressed to eat. 
Demented patients often bolt their food and gorge themselves. 
Epileptics are especially prone to this practice. Such cases re- 
quire careful supervision if not actual feeding. General paretics 
should always be fed. Even if they appear to have but little 
difficulty in swallowing, they should not be left alone with a tray, 
and where the slightest apparent difficulty exists, the utmost 
pains should be taken to feed them liquid food slowly and care- 
fully. 

All feeble patients (in fact all patients) should be fed slowly. 
The aged and those with poor teeth should have their food espe- 
cially prepared for them, the meat cut very fine, and special diet 
should be requested for such as are unable to eat the regular diet 
provided. 

In feeding patients who are loath to eat, try to cheer, encourage, 
and direct them. Sometimes, by engaging the attention of certain 
stubborn ones, you can get them to take food almost without their 
knowing it. Make no comments about this in their presence, con- 
tinue your cheerful talk and the feeding, and act as though noth- 
ing out of the ordinary had happened. 

Fill a cup or glass only part full when feeding helpless per- 
sons, raise the head slightly and support it firmly, having pre- 
viously placed a napkin under the chin ; then place the cup to the 
mouth, taking care to tip it just enough, and make an occasional 
stop for the patient to rest. When feeding cups are at hand, a 
very weak patient can often feed herself more comfortably than 
to have the nurse feed her. 

If a patient must lie on the back, the simple device of letting 
her draw up the nourishment through a bent glass tube will 
prove satisfactory. 

Exhausted patients requiring frequent nourishment often need 
to be awakened to take food; they usually drop off to sleep again. 

In feeding unconscious or delirious patients, or feverish ones, 
first moisten the lips with a swab made for the purpose, dipped in 



Chap. IX] PREPARATION AND SERVING OF FOOD 119 

glycerine and lemon juice. Then pass the partly filled spoon 
well back in the mouth, taking care not to touch the tongue if 
you can avoid it; empty the spoon slowly; then close the lips and 
nostril (of the unconscious patient), and the patient will swallow. 
Or the food may be dropped on the tongue with a pipette. 

Always wipe the corners of the mouth and the lips of helpless 
or careless patients during and after eating. The hands of bed 
patients should be washed before trays are carried to them; and 
the faces and hands, the bed and bed clothing made tidy again 
after the removal of trays. 

If patients are fed in bed, special care should be taken not to 
drop crumbs in the bed; if they feed themselves, this cannot be 
so well regulated. It is, therefore, important in the majority of 
cases that the nurses attend regularly to the removal of crumbs 
(and wrinkles) from the bed after each meal. 

Trays filled with glasses of water should be passed regularly 
in the hospital departments between meals, and the patients 
persuaded, urged, required, as the case may be, to drink the water. 
In some few instances, especially in failing heart troubles, the 
drinking of water, except in small quantities, may be contra-indi- 
cated. Such patients will doubtless be singled out by the physi- 
cian as exceptions to the general rule. 



CHAPTER X 

PRACTICAL POINTS IN NURSING THE INSANE 

I shall take it for granted, in touching upon the topics in this 
chapter, that the nurse is already conversant with the details of 
the various procedures in question, details which she is supposed 
to have learned from text-books on general nursing, from lectures 
in the Training School, and from instruction and practice on 
the wards. The procedures I particularly have in mind are the 
best methods of giving enemata and douches, of irrigating the 
uterus, of washing out the bladder and the stomach, of admin- 
istering medicines, making local applications, and applying 
massage. 

I shall merely refer to some of these and to a few other topics, 
in order to supply some details with special reference to the needs 
of the insane. 

In all these procedures the aim should be to do them deftly, 
with the least possible pain or discomfort to the patient, so as 
to secure the best results. Owing to the added difficulties 
that the nurse of the insane encounters, it is of even more than 
usual importance that everything needed for a given task be 
in readiness before the actual work with the patient is begun. 
An excited, resistive, or otherwise obstreperous patient is usually 
made more so by watching the haste and bustle of preparation, 
while if necessary preparation is neglected, and, in the midst 
of what is a trying task at the best, there is added the delay of 
waiting while some one who can be ill spared runs to hunt up 
necessary things, it is easy to see that confusion will reign, and 
perhaps failure be the result. 

Enemata. — It is frequently necessary to give insane persons 
enemata to secure an evacuation of the bowels and to control 
dysentery. Enemata are less frequently given for other purposes. 

120 



Chap.X] PRACTICAL POINTS IN NURSING 121 

One should never set about this without explaining, to all 
patients at all capable of appreciating it, what is to be done, 
and why. Time will be saved and resistiveness and violence 
often avoided by painstaking explanations. Especial care needs 
to be exercised to avoid injuring a struggling patient either by 
letting her become bruised from being held, or from throwing 
herself off the cot, from injuring the parts by too forcible or by 
unskillful use of the nozzle, and extra pains have to be taken 
to explain to the patient the necessity for trying to retain the 
enema as long as desirable, in order that it will be effectual, 
and will not need to be repeated. 

You will need to assist many patients to retain the enema by 
holding a folded towel close to the anus. 

Some malicious patients will take delight in evacuating the 
contents of the bowels before the nurse has the pan or other 
receptacle ready. Some deluded patients, governed by the 
belief that all their evacuations are of great value, have to be 
worked with for a long time before they can be persuaded to 
expel the contents of bowels or bladder. The nurse may need 
to assist in the emptying of the rectum by manual interference. 
When this is necessary, she should anoint the index finger 
of her right hand well with soap, and fill in the space around 
and underneath the nail with soap, as this prevents the fecal 
odor from clinging to the finger afterward. 

Have a special care that angry and violent patients do not get 
a chance to pull down the douche can, or tip over basins, or 
spill or break appliances close at hand. 

It is sometimes necessary to give patients nutrient enemata 
when for any reason food cannot be retained by the stomach, 
and when nasal feeding is not advisable. Remember that the 
rectum must be empty before giving the nutrient enema. The 
nutritive substance is injected through the long rectal tube 
passed at least eight inches beyond the sigmoid flexure; the 
hips should be raised on a folded blanket, and the patient re- 
quired to lie very quiet for at least a half hour afterward. As 
a rule from three to six ounces of the nutritive fluid, at 100° F., 
are administered every four or six hours. Beef tea, malted 
milk, Mellin's Food, eggs and milk, and the like, are given. 



122 NURSING THE INSANE [Chap. X 

The food is very slowly and carefully injected by pouring into 
an elevated funnel attached to the rectal tube. 

Vaginal Douches. — In the giving of vaginal douches especial 
care needs to be taken with struggling patients, as has been en- 
joined in the giving of enemata. Glass nozzles should seldom 
be used with patients at all likely to be resistive, because of the 
danger of their breaking within the body. 

Catheterization and Irrigation of Bladder. — It sometimes be- 
comes necessary to catheterize insane patients to obtain urine for 
analysis, to relieve retention, either voluntary or involuntary, and 
to prevent the flow of urine over inflamed parts, or over parts 
recently operated upon. 

Hot applications over the patient's bladder and the region 
of the kidneys, a hot sponge between the thighs, sitting over 
hot water, irrigating the vulva, a sitz bath, a hot pack, or a hot 
enema are means to be tried before catheterization is resorted 
to, and even then it is only to be done when ordered by the 
physician. 

The strictest antiseptic precautions in the cleansing of the 
hands, the cleansing of the parts, the care of and use of the 
catheter, in fact, in the entire procedure, must invariably be 
observed. More than ordinary care is needed in this respect 
with the insane, and also to avoid injuring patients who struggle 
during the operation. It is always better to introduce the 
catheter by sight in the insane than to do so under cover. Never 
use a catheter which is in the least danger of being torn or broken. 

In irrigating the bladder of insane patients, more than 
ordinary care needs to be exercised to avoid introducing too 
much water (less than a pint as a rule) without letting it run 
off, as such patients may fail to complain when pain due to 
discomfort is felt. 

Use of Stomach Tube. — It sometimes becomes necessary for 
the nurse to obtain the contents of the stomach for laboratory 
examination. In such instances the physician usually orders a 
test breakfast, specifying the food. It may be simply a cup of 
clear, unsweetened tea, and one or two soda crackers, or steak 
and bread and butter. In an hour's time after taking the food 
the nurse is to obtain the stomach contents by passing the 



Chap. X] PRACTICAL POINTS IN NUESING 123 

stomach tube. This tube, on entering the stomach, causes the 
walls to contract and expel the food. If it fails to do this, 
pouring down about two drams of lukewarm water will usually 
be effectual. The contents should be measured and immediately 
sent to the laboratory in a clean bottle, labelled with the patient's 
name, the ward location, and name of nurse, the date, the time 
of the breakfast and of securing the contents, and the quantity. 

Nasal Feeding. — Forced feeding through the nose is resorted 
to when a patient's condition, bordering on exhaustion, because 
of refusal of food or inability to swallow, demands it. Because 
of some delusion on the part of the patient, or some difficulty 
in swallowing, the physician may decide that mechanical feed- 
ing must be employed. 

Insane patients often refuse food because they think they 
cannot eat, or ought not to eat — perhaps that by so doing they 
are depriving others — or because they wish to die, and so 
resolve to die by starvation. A physician should always be 
present at the feeding, and should pass the tube the first time 
that this method is tried on a given patient. 

The nurse should tax her resources to the utmost before ad- 
mitting that she cannot get the patient to take sufficient nourish- 
ment. One nurse may succeed where another fails; the physician 
may be successful where the nurse fails; or a tactful patient 
may overcome the refractory patient when no one else can; or 
food left about for the patient to take when she thinks herself 
unobserved may accomplish the desired end. Leave nothing 
untried before admitting defeat. It is sometimes a good plan 
to let the patient witness another patient being forcibly fed; 
in some instances the repugnance aroused is sufficient to over-, 
come the refusal of food. As a rule, though, a patient who is 
being forcibly fed should be screened from others, except the 
ones necessary to assist in the operation. Sometimes one feed- 
ing accomplishes the desired end, but in other cases the feeding 
has to be continued weeks, months, years, as the case may be. 
Some patients lie quietly and submit to the introduction of the 
tube, some resist frantically, pull the tube out if they can, or 
regurgitate the food if they cannot succeed in removing the tube. 
Some will force the tube into the back part of the mouth, in 



124 NURSING THE INSANE [Chap. X 

which case it needs to be withdrawn and reintroduced. In a few 
instances patients have not only been known to submit willingly 
to the tube, but even to introduce it themselves. One deluded 
patient I have in mind argued that since the matter was beyond 
her control, and she was forced to take the food, though strenu- 
ously objecting to it, the Lord would not hold her accountable 
for food taken in this way, consequently she might as well suffer 
its injection with as little discomfort to herself as possible. 

In forced feeding, always have plenty of assistants at hand, 
so that the patient sees the uselessness of resistance. Never 
resort to feeding without explaining to a patient capable of 
understanding it, that it is the last resort, and that we much 
prefer that she take her food by the mouth. Sometimes, at the 
last minute, with all the appliances and assistants at hand, if 
a cup of milk is offered, the patient will yield rather than submit 
to the passage of the nasal tube. 

Have everything at hand before approaching the patient — 
a large towel to use as a bib, a stand on which to set the tray 
which should hold the feeding bottle with the food, the long 
rubber tube (size 13 American) for introducing into the nose, 
the small dish of olive oil for a lubricant to the tube, two or three 
towels, and an extra sheet. One towel folded lengthwise, so 
that it is about four inches wide, may be used, if necessary, to 
hold the head down to the pillow, thus avoiding bruising a 
struggling patient by making pressure with the fingers on the 
temples or forehead. 

The patient should be slightly propped up on pillows, the 
clothing about the neck loosened, and protected by a towel or 
a sheet; artificial teeth, if worn, should be removed, and a sheet 
placed across the patient's body over the knees, outside the 
bedclothes, and, if necessary, firmly held on each side by two 
attendants in order to prevent the patient from kicking or throw- 
ing herself about. Another assistant, in cases requiring it, 
holds the patient's wrists, taking care not to bruise her, nor to 
exert force unless it is necessary. You need to be on your guard 
to prevent the patient from pulling out the tube after it is in 
place, from kicking the assistants, from struggling so that the 
bottle of food is overturned, and from throwing herself on the 



Chap. X] PRACTICAL POINTS IN NURSING 125 

floor. She may also tear your hair, spit in your face, catch at 
your watch chain or key chain, or apron straps, and show other 
violent and malicious tendencies. 

The prepared food, properly warmed and salted, is brought 
in the bottle especially used for the purpose, fitted with a pump- 
ing apparatus and a long rubber tubing and nozzle, to which 
the free end of the feeding tube is attached, after the tube is 
introduced into the esophagus. 

The feeding tube may be oiled or dipped into the feeding 
mixture to make it pass easily ; it is then introduced into one 
nostril, using only mild pressure as it is pushed along the floor 
of the nasal chamber. Care should be taken not to rotate it. 
When it reaches the pharynx, it may meet with some obstruction, 
or it may pass readily down the esophagus, or may, rarely, enter 
the larynx. Great care is necessary at this point. When the 
tube meets with obstruction, tell the patient to swallow; if 
she obeys, it will be sufficient to let it pass; sometimes it will be 
necessary to withdraw it a little way, then by making slight 
pressure it will find its way into the esophagus; or you may 
need to withdraw it entirely and try the other nostril. After 
the tube has passed down, say about eighteen inches, and there 
has been no embarrassment, no strangling or coughing, and 
if you can feel no air coming out at the free end of the tube, 
you may be sure that the tube is where you have been trying to 
put it — in the stomach; but if, before passing to such a distance, 
cyanosis of the face, strangling, or any of the above-mentioned 
symptoms are noticed, you must quickly withdraw the tube, 
as the chances are you have introduced it into the larynx. Pa- 
tients often get very red in the face from struggling, but if the 
tube has gone down the right way this need not deter you from 
connecting the free end with the nozzle of the tubing on the 
feeding bottle, and proceeding to pump in the liquid. This should 
be pumped steadily and leisurely, watching the lowering of the 
fluid in the bottle and discontinuing before it gets so low that 
there is danger of introducing air into the stomach. Quickly 
disconnect the feeding tube from the bottle nozzle, then quickly 
withdraw the tube, immediately on its withdrawal gathering 
it into the towel previously shaken out, not allowing the tube 



126 NUKSING THE INSANE [Chap.X 

to trail over the patient's mouth or chin, and taking care, as the 
tube is removed, to cleanse the nostril from the mucus that is 
usually seen at the entrance on the withdrawal of the tube. 
Pinch the outer end of the tube to prevent dripping of the liquid 
upon the bedding or the patient. Encourage the patient to lie 
quietly after the feeding. 

In some cases it is necessary for an assistant to hold up the 
lower jaw by pressing up against the angles and the lower border 
of the jaw, during the introduction of the tube, bending the 
head slightly backward. It may also be necessary to continue 
holding the head in this way for several minutes after the feed- 
ing, in certain cases, to prevent the patient from regurgitating 
the food. Persistence in bringing the food up as soon as it is 
down may sometimes be corrected by repeating the entire 
process immediately, when the patient, seeing that her conduct 
will not prevent another feeding, will often desist rather than 
to have the disagreeable measure repeated. 

Various fluids are used in forced feeding — hot milk, Mellin's 
Food, malted milk, beef tea, milk and eggs with extract of beef, 
and other nutritious and well-strained mixtures. 

It is well to close the feeding by adding four or five ounces of 
water if the patient refuses water by the mouth, or to add this 
amount of water to the feeding mixture. 

The food should be varied from day to day, and the quantity 
and frequency regulated by the physician. In the majority 
of cases, from one and one-half to two pints are given at a feed- 
ing. 

Milk used for nasal feeding is usually thickened with flour 
and salted. On some days this is thickened with boiled potato 
instead of flour, again with beans, peas, corn meal. Sometimes 
one ounce of the juice of raw potatoes (or other vegetables) is 
added to each pint of milk used. Prune juice may be added 
to the feeding mixture. Thick soups and broths of various kinds, 
diluted with beef tea, so as not to clog the feeding apparatus, 
are used for forced feeding. The tube should be promptly 
cleansed in cold water after being used, and the bottle rinsed 
in cold water, then thoroughly washed and rinsed and made 
ready for the next feeding. 



Chap. X] PRACTICAL POINTS IN NURSING 127 

The Administration of Medicine. — In giving medicines to de- 
lirious patients they may often be helped to swallow by first 
moistening the lips and rubbing the spoon against them. Un- 
conscious patients should not be given medicine unless expressly 
directed by the physician, as suffocation or strangling may result; 
but when given, it should be placed far back upon the tongue, 
and in liquid form. 

When medicines are given from spoons, the spoons should not 
be so full as to spill and let the liquid run down the chin. 
They should be carried with a steady hand, and given from the 
point of the spoon; a clean towel or napkin should be at hand 
to wipe the lips, or, in case of resistive patients, to protect 
clothing and bedding. 

The forced administration of medicine should never take 
place except when so ordered by the physician, nor should 
medicines ever be put in the food unless so ordered. 

Medicines should be given promptly and quietly, avoiding 
as much as possible letting the patient see preliminaries. Con- 
valescent and able-bodied patients should go to the medicine 
closet at the prescribed intervals, on signal of the nurse, and 
bed patients should have medicine carried to them and ad- 
ministered by the nurse, never by a patient, however trusty 
one may be. 

Medicines are to be kept in the locked closets arranged for 
them. Nothing is to be permitted in these places except such 
articles as are expressly allowed by the institution in which you 
are employed. A list of contents, always up to date, should be 
fastened inside the medicine closet in a conspicuous place for 
ready reference. 

Lotions, local applications, and disinfectants are on no account 
to be kept in medicine closets, but are to be kept locked 
in special compartments assigned for their safe keeping. All 
poisonous medicines must have a conspicuous label indicating 
the same. No patient, however trusty, is to be permitted even 
momentary access to the medicines or disinfectants. All 
medicines are to be transferred immediately from the custody 
of the drug clerk to the medicine closet, in no instance being 
allowed to remain elsewhere till a more convenient season. 
As soon as received, the names of the medicines, the dose, and 



128 NURSING THE INSANE [Chap. X 

the directions for giving are to be transferred by the charge 
nurse to the nurse's medicine book, under the patient's name. 
Medicines no longer in use are to be promptly crossed off the 
book and returned to the pharmacy. 

The most conscientious attention must be paid to the ad- 
ministration of each prescription exactly as ordered, unless the 
patient is sleeping, in which case, if not expressly stated other- 
wise, it is well not to awaken the patient. 

Empty bottles, envelopes, and boxes which have contained 
medicine, and all medicines ordered discontinued, are to be re- 
turned to the drug room. 

Unless a medicine is plainly marked with the dose and the 
directions for administration, the nurse must refrain from giving 
it, but must report the same to the physician in charge. There 
must be no guesswork in any instance. If medicine comes to 
a given ward marked for a patient, but with a mistake in the 
initials, or in the given name, it may be intended for a patient 
on another ward; the nurse must ascertain without a doubt for 
whom it is intended. 

Refusal to take medicine, if it cannot be overcome by per- 
suasion, should be reported to the physician, who will direct 
whether force or subterfuge shall be resorted to for its admin- 
istration. 

In each case of administering a dose you should assure your- 
self that the medicine has been swallowed. The insane are 
often very suspicious, especially concerning drugs; they will 
sometimes resort to all sorts of means to avoid swallowing them. 
Some will spit them out, either upon the floor or the bedding, or 
slyly in a handkerchief; others will hold them in the mouth till 
the nurse's attention is diverted, and then eject them out of the 
window, behind radiators, down the wash bowls or water-closets. 
It is a good plan to engage a suspected patient in conversation 
at the time of administration; inability to get him to reply, 
unless he is in a stupor, or is a case of mutism, or is actually 
mute, or too demented to talk, ought to put you on guard 
to see if he is not rejecting his medicine. If you suspect, or 
feel convinced of this, it is well not to let him know of your sus- 
picions, but to let the physician know, as the case may require 



Chap. X] PRACTICAL POINTS IN NURSING 129 

very careful handling, the details of which the physician will 
wish to arrange. 

It is very important, in applying either dry or moist hot ap- 
plications to insane patients, to use the utmost care, both in 
applying and in leaving the applications in place, that the pa- 
tients shall not be burned. Unconscious, stuporous, paralyzed, 
and demented patients need to be especially safeguarded in this 
particular. 

Massage. — Massage cannot be properly learned except from 
an experienced teacher, and skill can come only with practice after 
thorough instruction has been received. The masseur or masseuse 
should be strong and well, fastidious in person and attire, free 
from any skin affection, from a bad breath or catarrhal or other 
objectionable odors, and free from the use of strong perfumes or 
tobacco. The hands should be strong, soft, and supple, the 
motions well-defined, purposeful, methodical; there should be 
no flurry, hurry, jerkiness, or fussiness. 

Nervous patients need especially to be taught to relax the 
entire body as completely as possible, to lie passive, giving the 
body over, for the time being, to the care of the masseur, only 
trying to help in so far as to obey is to help. The nervous or 
mental patient, as a rule, should not be engaged in conversation, 
nor encouraged to talk, even if he seems so disposed; neither 
should he be talked to, except a few quiet, cheery words at greet- 
ing and parting, and the necessary talk incident to the work at 
hand. At the close of the treatment he should be allowed to 
lie quietly in the blanket and rest for an hour, whether he can 
sleep or not. 



CHAPTER XI 

THE OBSERVATION OF SYMPTOMS 

Nurses are with patients so continually and see them under 
such varying conditions that the help which they can render by 
intelligent observation is incalculable. But one needs to know 
what to look for, and to adopt a systematic way of observing a 
case — needs to know what is normal before the abnormal 
condition can be recognized. 

The general appearance of the patient, including his physical 
condition, his behavior, habits, and peculiar mental manifesta- 
tions, are headings under which the nurse may group her obser- 
vations. 

As much as possible should be ascertained without asking 
questions. It is what you notice that the physician wishes to 
learn. In most instances it is better to leave the questioning 
to the physician. Above all, do not be indiscreet in your obser- 
vations, interrogations, or comments. Be especially considerate 
concerning deformities, as persons having them are usually 
sensitive about them. 

By symptoms we mean the manifestations of disease or injury. 
These are classed as subjective and objective. Subjective symp- 
toms are those which the patient experiences; we must rely 
upon him for information concerning them. Great care is 
necessary in determining how much weight to give to subjective 
symptoms, for patients, consciously or unconsciously, often 
exaggerate or make light of their feelings, or even profess to have 
certain symptoms which they do not have, or deny having those 
which they do have. We call a person a malingerer who pro- 
fesses to have symptoms which he does not have. 

Among the most common subjective symptoms are pain, 
vertigo, nausea, tenderness, increased sensibility, loss of sensi- 
bility, sensations of numbness, crawling, burning, itching, bad 

130 



Chap. XI] THE OBSERVATION OF SYMPTOMS 131 

taste in the mouth, noises in the ears, spots before the eyes, 
an undue sense of fatigue, and the like. 

It is the nurse's duty to report all subjective complaints 
whether she believes them to be real, exaggerated, minimized, 
or feigned; but if she has good ground for believing them to 
be simulated, it is proper for her to mention such grounds. Let 
it be remembered that these very subjective complaints, even 
when exaggerated or feigned, may be of the utmost importance 
to the physician. In early cases of mental alienation it is espe- 
cially important to note the complaints of changes in the organic 
sensations, for these are often of such a nature as to interfere 
with the combination of sensations that make up the patient's 
individuality, and the study of these is often of the greatest help 
in tracing the beginnings of the alteration of the ego, in other 
words, of seeing the bridge across which the person passes from 
sanity to insanity. 

Objective symptoms are those which may be detected by others. 
In addition to having acquired by practice accuracy of observa- 
tion, the nurse needs to learn what symptoms demand immedi- 
ate attention and what can afford to wait until the physician's 
regular visit. It is always better to err on the safe side if a 
symptom seems at all urgent than to fail to call a physician and 
later find that you have made a serious error in judgment. 

Nurses of the insane need to remember how important it is 
to observe the so-called silent symptoms, for insane persons are 
often unable to tell when they feel sick or how they are ailing. 
Only by quiet crying or slinking away in a corner on the floor, 
or going to bed, or refusing to eat, or in some such way, do cer- 
tain persons show their indispositions. 

For convenience, and in order that a method may be followed 
in making observations, the following outline of examination 
is offered: — 

Name of patient Date of observation Ward location Name of nurse 

GENERAL APPEARANCE OF PATIENT 

Dress — tidy, untidy, clean, unclean, precise, slovenly, fantastic, fastened 
imperfectly or carelessly regarding decency; droppings of food; shoes, 
where most worn, if disorders in gait are noted. 



132 NURSING THE INSANE [Chap. XI 

Behavior — timid, reckless, modest, bold, docile, unruly, mild, boisterous, 
meek, boastful, indifferent to surroundings, interested, overcurious, mis- 
chievous, restless, apathetic, occupied, idle, destructive, oversensitive, peace- 
able, threatening, nighty, poor control. 

State of nutrition and apparent or real weight and height — emaciated, 
slender, well nourished, stout, obese, dwarfish, short, medium, tall, very tall. 

Complexion — fair, dark, medium, sallow, ruddy, florid. 

Hair — color, texture, quantity, baldness (general or local). 

Eyes — color, expression, appearance of pupils. 

Facial expression — calm, happy, anxious, worried, suffering, dejected, 
elated, egotistical, shrinking, pinched, tranquil, dull, stupid, bewildered, 
besotted, delirious, dazed, convulsed, etc. 

Carriage and posture of body — walking, erect, bent, staggering ; sitting, 
erect, stooping; lounging, lolling about, etc.; lying down, apathetic, rest- 
less, sliding down in bed, etc. Manner of moving about, impairment of 



OBJECTIVE SIGNS IN SPECIAL ORGANS AND PARTS 

Note if there is anything unusual in appearance or condition of : — 
Head and face, and organs of special sense; neck or throat; chest; back 
or abdomen; extremities; genital organs; skin. 



SUBJECTIVE COMPLAINTS 

Pain, tenderness, abnormal sensations, numbness, nausea, vertigo, etc. 
Is pain sharp, dull, burning, stinging, darting, band-like, needle-like, con- 
stant, intermittent, spasmodic? 



MENTAL STATE 

Intellectual field — conscious, unconscious, dull, alert, rational, irrational, 
delusions, hallucinations, illusions, hobbies, queer ways, perversions, lapses 
in memory, fabrications, disorders in speech, misapprehending of persons 
and surroundings, suicidal or homicidal tendencies, self -accusations, ideas of 
reference, or of undue or unfair influence. 

Emotional field — self-controlled, or rapidly changing and uncontrolled 
emotions, happy, sad, cheerful, joyous, morose, irascible, signs of affection, 
love, rage, fear, dread, hopefulness, jealousy, envy, sympathy, merriment, 
grief, zeal, ennui, feeling of unreality, credulity, doubt, aspiration, elation, 
depression, hesitation, indecision, timidity, anxiety, irritation, contentment, 
pride, humility, admiration, patience, scorn, rebellion, abhorrence, contempt, 
disgust, pity, impatience, expansion and ease, or contraction and tension, 
sensitive to the beautiful, the sublime, the comic, etc. 



Chap. XI] THE OBSERVATION OF SYMPTOMS 133 

This outline merely furnishes one with hints as to what to 
observe, and the general order in which to proceed. 

Let it be clearly understood that in your observations you 
are to take in these things so quietly and unostentatiously, 
while undressing and dressing, bathing, and otherwise caring 
for the patient, while talking with her and watching her when 
she considers herself not under observation, that she gets little 
or no hint that you are doing anything other than being attentive 
to her needs. 

Sacrifice your observations every time rather than subject 
the patient to unpleasantness, or incur displeasure or anger, 
or arouse the suspicion that you are scrutinizing her. 

In taking into account the respiratory rate, one needs to remem- 
ber that it is naturally increased after eating, after exercise, 
and by any strong emotion. Pain usually increases it ; it becomes 
accelerated with an increased temperature; in hysteria it is 
often quickened, and it is usually appreciably increased in 
phthisis. It is decreased in coma, poisoning, shock, and in 
stupid states, as in dementia precox. 

To count the respirations, watch the rise and fall of the chest 
or the upper abdomen, or lay the hand lightly upon the lower 
chest; if one knows that he is being watched, it naturally increases 
his respiratory rate, so that it is better to keep the fingers on 
the pulse while determining the respiratory rate, and so let the 
patient think that it is his pulse instead of his breathing that 
concerns you. Or count the respiration while taking the tem- 
perature, watching the rise and fall of the clothing over the chest. 

In preparing a patient for a chest examination, strip all 
clothing from the chest, and if the patient is strong enough, 
have him assume the standing position. Wrap a sheet around 
him until the physician is ready to begin inspection of the 
chest. The room should be comfortably warm so that the patient 
does not feel chilled from the exposure. Wash under the arms, 
drying the skin thoroughly, and if the perspiration is profuse or 
offensive, dust toilet powder or cornstarch in the axillae. Have 
a clean towel ready, and dry any perspiration that may form 
during the examination. It is very unpleasant for a physician 
to have to put his fingers in a sweating axilla. Have ready 



134 NURSING THE INSANE [Chap. XI 

soap and a basin of warm water and a towel, or at least a clean 
towel with one end moistened for the physician's use. If the 
patient's skin is very dry and harsh, it is well to oil it before the 
examination, to avoid confusing friction sounds. Try to keep 
the room as quiet as possible during the examination. 

Learn to describe fully the character of the various coughs 
and the appearance of the sputum. Coughs may be dry, loose, 
hacking, barking, rattling, paroxysmal, suppressed, croupy, 
etc. Sputum may be watery, blood-tinged, viscid, mucous 
or muco-purulent, purulent, rusty, like prune juice, or it may 
consist of clear blood 

There are certain symptoms which should make the nurse 
suspect trouble with the heart and blood vessels. Some of 
these are difficult breathing, especially if made worse by exercise, 
and accompanied by blueness of lips and face; swelling of the 
feet and ankles, palpitation, pain in the region of the heart, anxi- 
ety and fear of death, sudden dizziness, restless sleep, starting in 
sleep, chronic cough, chronic digestive disturbances, and obesity. 
The nurse should report any of the above symptoms, and should 
examine the chest for distended veins, pulsations in the large 
blood vessels of the neck, or in the pit of the stomach, and should 
note if the apex beat of the heart is especially conspicuous. 

The rate and character of the pulse should be carefully studied. 
The patient should be lying down or sitting, and should not have 
made undue physical exertion just previous to the taking of the 
pulse. In susceptible persons the mere act of another's counting 
the pulse increases its rate, so it is well to let patients get ac- 
customed to your finger being on the pulse before you begin 
counting for the purpose of recording it. The patient's forearm 
should be half prone, the tips of the index and second fingers 
should be placed on the radial artery, which is usually felt 
pulsating on the outer side of the wrist. There is sometimes an 
abnormal course of the artery, so that you may have to hunt for 
the pulsation other than in the usual place. It is better for the 
nurse to count the pulse for a full minute than to count for 
half a minute and multiply by two. 

Note if the beats are regular, whether they skip a beat occa- 
sionally, whether you can feel the artery roll under your finger, or 



Chap. XI] THE OBSERVATION OF SYMPTOMS 135 

whether by pressing on the artery the pulse becomes less distinct 
or not. 

If a patient complains of feeling chilly, looks flushed, or acts 
sick or " dumpish/ ' or refuses food, it is well to take the tempera- 
ture. For accuracy, rectal temperature is the most reliable. 
If the temperature in the axilla is 98° F., it will be about 98.6° 
in the mouth, and 99.5° in the rectum. 

It is very necessary to explain what you are about to do to 
insane patients, and thus avoid frightening or shocking them by 
these investigations. The temperature should never be taken 
in the mouth of suicidal or very excited patients, as there is 
danger of their biting down on the bulb of the thermometer, 
and of swallowing the glass. When taking mouth temperatures, 
if the lips are dry and cracked, they should be moistened so that 
they will fit closely around the stem of the thermometer. Do 
not take the temperature immediately after the patient has been 
given hot or cold drinks or cracked ice. When the temperature 
is taken in the axilla, first diy the skin, then place the bulb well 
in the hollow, and hold the arm firmly to the side. When rectal 
temperature is taken, first make sure that the rectum is free 
from feces, oil the bulb and insert it carefully one and one half to 
two inches, the patient lying on the side. 

In most insane patients it is necessary for the nurse to give 
her undivided attention to the patient while the thermometer 
is in place, in order to avoid attempts to break it, to swallow it, 
or otherwise to thwart the investigation. Always record where 
the temperature has been taken. 

To prepare a patient for examination of the abdomen by the 
physician, turn down all the bed clothing but the sheet, then, 
under cover of the sheet, draw the nightgown up as far as the 
margin of the ribs. When the physician is ready, fold the sheet 
down to just above the pubes. Have the patient lie on the back 
as evenly as possible, and let the light fall upon the abdomen. 
In obese patients, be particular to bathe, dry, and dust the skin 
under the mammae and under the fleshy and pendulous parts 
of the abdomen, as these parts lying in apposition become moist 
and often offensive unless care is used. Have warm water, soap, 
and a towel ready for the physician's use. 



136 NURSING THE INSANE [Chap. XI 

If there is vomiting, ascertain whether the vomitus consists 
mainly of food, or whether the ejection of food is followed by 
a watery or mucous substance, by bile, blood, fecal matter, 
or worms, or whether it has the odor of any drug. 

The nurse needs to watch her patients while they eat in order 
to learn whether they chew their food sufficiently, or bolt it, 
whether they eat with apparent relish or force themselves to 
swallow each mouthful; what food seems most acceptable, 
what most distasteful. She should note and report a capricious 
or ravenous appetite, and should observe if eating is accompanied 
by apparent discomfort, nausea, or vomiting. Is the refusal 
of food apparently due to loss of appetite, or to delusions? 

By anorexia we mean loss of appetite; bulimia is increased 
appetite, and pica is depraved appetite for unwholesome, in- 
digestible, and disgusting things — a condition sometimes seen 
in pregnancy, hysteria, anemia, and often in idiots, and in the 
insane. 

It is the duty of the nurse of the insane to acquaint herself with 
the regularity and frequency of the bowel movements and the 
appearance of the stools of every new patient who comes under 
her care, and these investigations should extend to the older 
cases, even though in a lesser degree, especially in the deteriorated 
class of patients who are incompetent to attend to and report 
concerning themselves in this particular. 

Constipation may be due to the insufficient taking of waste 
material in the food, to a too scanty ingestion of liquids, to 
overdistension of the intestines with food, to stupid states, to 
dependence upon cathartics and enemata, to hernia, to intestinal 
obstruction, and to many other causes. One of the most frequent 
causes of this symptom is neglect and laziness on the part of the 
patient — a failure to train the intestines to regular habits of 
evacuation. 

Diarrhea may consist of only three or four loose stools in 
twenty-four hours, or it may present all degrees from this to the 
almost continuous purging of dysentery. Like constipation, it 
may be caused by a great number of conditions. These may 
be psychic as well as physical — emotional shocks, anticipations, 
pleasurable or otherwise, unusual events may give rise to it, 



Chap. XI] THE OBSERVATION OF SYMPTOMS 137 

especially in neuropathic persons. Inflammatory conditions of 
the intestinal tract are the most common causes of diarrhea, 
and these may be brought about by many and varied things. 

The nurse needs to remember that the patient may have 
diarrhea and still be constipated. The feces may collect in 
hard masses in the colon and yet a channel remain so that a 
loose stool passes, the result of the irritation to the mucous 
membrane caused by the hardened masses. An accumulation 
of feces in the abdomen is usually discovered by the doughy 
feel to the mass, which can be indented as a rule. The passage 
of hard fecal masses (scybala) should always make one suspect 
constipation. 

Stools may be formed, fluid-fecal, semi-fluid, or fluid in con- 
sistence. Milk diet makes them light yellow; clay-colored 
stools indicate a deficiency of bile, green stools are not uncommon 
in the diarrhea of infants, and after calomel, or where there is an 
increased secretion of bile; black stools may be due to the use 
of iron or other drugs; blood in the stools may give a red or 
tarry color. As a rule, bright red blood in the stool comes from 
the rectum, from hemorrhoids, fissures, or ulcers, while tarry 
stools show the origin to be higher up, and probably due to gastric 
or intestinal hemorrhage. In the insane, when blood in the stools 
is noted, we should suspect the presence of foreign bodies in the 
rectum, causing irritation. When we reflect that a rubber heel, a 
key chain, false teeth, and other incongruous articles have been 
extracted from the esophagus of patients, that an ordinary 
silver teaspoon has been found in the intestines of a patient at 
autopsy, and that a five-inch iron bolt has been found in the 
cecum at operation, and that masses of hair, rags, ravelings, 
and other foreign bodies are frequently found in the stomachs 
and intestines, and sometimes in the vagina, at autopsies, we 
need to be constantly on guard to see that the rectal and vaginal 
passages are not furnishing hiding places for foreign bodies. 

Urination may be natural, painful, difficult, slow, frequent; 
there may be incontinence, retention, suppression. Painful 
urination is most frequently due to inflammation of the bladder 
(cystitis), but may also be due to growths or ulcerations of the 
bladder or of the urethra, to stone in the bladder, gravel, and 



NURSING THE INSANE [Chap. XI 

other conditions. Difficult or slow urination is due to any con- 
dition that obstructs the urethra or impairs the muscular power 
of the bladder. Frequent urination is often seen in nervous 
persons, in diabetes, and in conditions where abnormal constitu- 
ents cause irritation. 

Incontinence or inability to hold the urine is due to loss of 
control of the sphincter muscle of the bladder. Retention of 
urine may exist with incontinence or with frequent urination, and 
so is likely to be overlooked. It is common in typhoid states, 
in hysteria, and in enlarged prostate, and is sometimes seen in 
demented patients. It is manifested by overdistension, and 
later by constant dribbling. Suppression of urine is the con- 
dition where urine is not secreted by the kidneys. If a catheter 
is passed and the bladder found empty when no urine has been 
voided in a reasonable time, suppression is easily differentiated 
from retention. Uremia may follow suppression, and death will 
not be long in coming if the condition persists. 

The appearance of urine as to color — pale, light straw color, 
amber, dark amber, brown, reddish — should be described; 
whether it is clear, cloudy, opaque; whether it has its character- 
istic odor, or a strong ammoniacal odor, or is otherwise offensive; 
whether there appears to be mucus, pus, or blood in the sediment, 
and whether or not the voiding of urine is accompanied by pain; 
if so, where, and of what nature ? 

Collecting Specimens for the Laboratory. — In collecting and 
sending specimens to the laboratory, the nurse needs to be very 
exact in her methods, or the time of the physician is almost 
thrown away in studying specimens, and false conclusions may 
be arrived at. The name of the patient, the ward location, and 
the date on which the specimen is obtained should accompany 
each specimen. In all these procedures the receptacle must be 
absolutely clean, preferably sterilized, and so dried and cared 
for after sterilization that lint, dust, and bacteria are not allowed 
to collect upon it. It must also be tightly corked or otherwise 
protected, and promptly sent to the laboratory. 

When sputum is sent, it should be as free from saliva as possi- 
ble. It should be brought up by coughing or hawking. The 
best time for the collection of sputum is early in the morning, be- 



Chap. XI] THE OBSEEVATION OF SYMPTOMS 139 

fore food has been taken ; where the patients will cooperate, it is 
well to have them rinse the mouth previous to collecting the speci- 
men, to dispose of as much of the tissue waste as possible. A 
very small amount of sputum is sufficient. It is often difficult to 
obtain a specimen of sputum in the insane under any conditions, 
especially in tubercular cases. It is well for the nurse to obtain 
a specimen even under unfavorable conditions rather than to 
obtain none at all, but when she cannot observe the ideal 
methods, she should accompany the faulty specimen by a note 
of explanation sent to the laboratory. 

In all new cases a specimen of urine should be sent to the 
laboratory as early as possible. A four-ounce specimen, collected 
the first thing in the morning, should be sent in all cases where 
it is not practicable to secure a twenty-four-hours' specimen. In 
female patients, be particular that discharges from the genital 
tract do not get mixed with the urine. 

Do not send a specimen that purports to be a twenty-four- 
hours' specimen unless it is one. Any deviation from that fact 
should be so stated in a note accompanying the specimen. 

In order to save a twenty-four-hours' specimen, begin, say at 
7 a.m. Discard any urine now contained in the bladder at the 
hour you begin the observation, as this has been secreted by the 
kidneys some time before. After rejecting this specimen, save all 
urine passed from 7 a.m. on a given day till 7 a.m. the second 
day, and promptly send it to the laboratory. It will be seen how 
important is the conscientious cooperation between the day and 
night nurses, if these aids to diagnosis are to be relied upon. 

You are confronted with many difficulties in making these 
observations upon the insane, owing to the carelessness and 
mischievousness of some, and the deluded states of others, but 
in a large number of cases, if you will take the pains to explain 
to the patient the reason for accuracy, you will find intelligent 
and often grateful interest shown, while in the unmanageable 
ones you will have to be continually on your guard to prevent 
them from thwarting your efforts. 

To collect a specimen from a discharging sore, receive a few 
drops on a pledget of sterilized absorbent cotton, then place in a 
clean phial, cork tightly, and send to the laboratory. 



140 NURSING THE INSANE [Chap. XI 

In collecting specimens from the throat or pharynx, a swab 
made and fastened in the stopper of a glass test tube is used. 
This is previously sterilized. When ready to obtain the specimen, 
the stopper with the attached swab is removed from the tube, 
and the pharynx swabbed out, whereupon the swab is imme- 
diately returned to the tube and sent to the laboratory. 

The male generative organs need to be observed for any unusual 
appearance of the parts — adherent prepuce, scars, sores, dis- 
charges, varicose veins, enlarged glands, hernia, and any swell- 
ings. The habit of masturbation is to be borne in mind, and 
patients of both sexes need to be observed closely in reference 
to it. The female generative organs should be observed for 
abnormalities in form, undue proportions, or atrophy of the 
external parts, vaginal discharges, sores, scars, eruptions, growths 
on or near the genitals, excoriations or growths near the urethra, 
rupture of the perineum, prolapsus of the vaginal walls or of the 
uterus, vermin, etc. If there is leucorrhea, its character, quan- 
tity, and time of appearance should be as accurately noted as 
possible. Absence of menses should be reported. Painful 
menstruation, or irregular or profuse menstruation, should be 
noted with as specific explanations as possible in regard to time, 
quantity, character of blood and accompanying symptoms. 

The skin is to be observed as to cleanliness, coarseness or 
fineness, smoothness or roughness, presence or absence of scratch 
marks, vermin, eruptions, sores, scars, old or recent, and bruises. 
Is it hot or cold, dry, moist, or clammy? Note its color, as 
healthy, ruddy, tanned, pale, extreme pallor, sallow, cyanosis, 
flushing, jaundice, colored patches, or lines. Localized sweating 
and offensive sweating should be noted, also general sweating 
and its accompaniments. 

The nurse needs to remember that pallor of the face may be 
due to anemia, to sudden loss of blood, to nausea, pain, faintness, 
or to strong emotions, as fear or anger. The face is red in fevers, 
in alcoholic conditions, in apoplexy and in excitement, as a 
rule. Circumscribed red spots are often due to vaso-motor 
disturbances, and show unstable emotional conditions. A hec- 
tic flush on the cheeks may be caused by phthisis, by septic 
conditions, and by excitement. The flush in pneumonia is 



Chap. XI] THE OBSERVATION OF SYMPTOMS 141 

usually a deep red; it may be seen on one or both cheeks. A 
bluish look about the lips and mouth is due to imperfect oxygen- 
ation of blood. A yellowish skin may be the natural hue, or 
may be due to life in Southern climates, to jaundice, to cancer, 
or to the opium habit. Bright' s disease often gives a peculiar 
waxy, white look; Addison's disease, a bronze shade to the skin. 
If there is swelling in any part, it is important to note if the skin 
pits on pressure. 

In your observation on patients remember that it is not enough 
to make the original report. Be particular to note and report 
progress, deterioration, or a stationary condition, as regards 
physical conditions, behavior, habits, emotions, beliefs. No 
cases are as stationary as they seem to a casual observer. Do 
not hesitate to call the physician's attention to peculiarities 
frequently. With several hundred patients in his service, he 
cannot carry the details of each case in mind without your help. 



CHAPTER XII 

ACCIDENTS AND EMERGENCIES 

The nurse for the insane has to be prepared to meet the unex- 
pected at every turn. Insane patients are liable to the same 
accidents and emergencies that befall the sane, and to many 
others in addition. Because of stupidity in deteriorated cases 
many accidents come about; because of mischievousness or 
malice, or of uncontrollable impulses, others result; false beliefs 
dominate certain patients, causing them to do violence to their 
fellows; sudden convulsive seizures subject their victims to 
accidents; self-injuries are inflicted, suicide is often attempted, 
and homicidal or at least dangerous assaults are by no means 
infrequent. 

The best way to meet accidents and emergencies is to meet 
them more than halfway. Cross these bridges before you come 
to them; in other words, forestall them by foresight and super- 
vision. A proper precaution prevents many unfortunate hap- 
penings. The nurse who keeps a watchful eye on her aged, 
feeble, and paralytic patients, guarding them against blows 
and falls, will prevent many a fracture and dislocation that 
would otherwise occur. Such patients easily topple over if 
jostled against, they slip on polished floors, stumble over rugs 
and small obstacles, often attempt feats they are unequal to, 
and are sometimes so annoying that they bring upon themselves 
the wrath of irascible ones. For such, eternal vigilance is 
required of their caretakers. Epileptics also call for constant 
supervision in order to keep them from falling, from scalding 
themselves, burning themselves by falling against radiators 
or grasping hot-water pipes, getting caught in machinery, or 
from sustaining other injuries. Certain ones require watching 
after convulsions, and between them, to prevent dangerous 

142 



Chap. XII] ACCIDENTS AND EMERGENCIES 143 

attacks upon others. Contentious patients and those given to 
sudden impulsive outbursts are prevented from beginning their 
assaults much more easily than the results of their assaults 
are handled. The same thing is true of suicidal attempts. 
Let your supervision be so constant and so thorough that the 
chances for accidents and emergencies can rarely occur. When 
they do occur, immediately report the injuries received to the 
physician. If the injury requires the physician's attention, a 
written account of just what has occurred is the safest one to 
send, especially if he is at a distance, so that he may know just 
what appliances to bring with him. It is risky trusting to the 
verbal messages of frightened bystanders. Select as trusty a 
messenger as you can, and be explicit in either oral or written 
statements. In hospitals, your communications can usually be 
transmitted over the telephone. Be explicit as to the patient's 
name, ward location, and the nature of the accident. 

In dealing with all emergencies, the main thing is to see clearly 
what to do, and to do it quickly but calmly. In order to cope 
with difficulties well, we must prepare ourselves beforehand 
by as thorough an understanding as possible of what are the 
right things to be done in the accidents and emergencies likely 
to present themselves. In all instances get rid of the useless 
bystanders if possible. 

In a hospital with conveniences and plenty of help close at 
hand, and physicians within easy call, the resources of a nurse 
are not always taxed as severely as when she finds herself in 
private nursing or out in the world, with only her wits and her 
empty hands to meet the demands of the situation. 

Emergencies in general have a way of coming up in the most 
inconvenient places and at the most inopportune times, taxing 
one's judgment and ingenuity to the utmost. At such times 
the nurse finds she must utilize whatever means are at hand, 
however incongruous they may seem, in place of the conveniences 
she is accustomed to be surrounded with. 

The nurse is at all times supposed to set an example to others 
of calmness and self-control; she will be expected to " keep 
cool," and to know how and when to act, and when to refrain 
from acting, which is often quite as important as to act. It has 



144 NURSING THE INSANE [Chap. XII 

been said that if one has but three minutes in which to act, at 
least one minute should be used in thinking what course to adopt, 
then pursue it as calmly and directly as possible. 

Unconsciousness or Coma. — Let us first consider unconscious- 
ness or coma. This may be partial or complete. It may result 
from a variety of causes, and according to what has given rise to 
it the treatment must vary. Unconsciousness may accompany 
f am ting or hysteria; it may be due to convulsions of various 
kinds, to apoplexy, intoxication, sunstroke, poisoning, shock, 
blows on the head, anemia, etc. In all cases of unconsciousness 
or semi-unconsciousness, be particular not to say anything in the 
patient's presence that it would not be desirable for him to hear. 

Fainting or Syncope. — In fainting or syncope, the uncon- 
sciousness is due to some failure of the heart to send the blood 
to the surface of the body and to the brain. Consequently the 
head must be kept low to help overcome this difficulty. Mild 
attacks of fainting last only a few seconds, more severe ones last 
several minutes, or even longer. Of course, if the fainting is due 
to loss of blood, the main thing is to check the flow, but it may 
be due to a weak heart, to insufficient supply of air, to tight 
lacing, or to emotional or other shocks. 

In cases of fainting, the person usually becomes pale and limp, 
and falls unless prevented. The pulse is very feeble, the breath- 
ing superficial and slow, the extremities cold, and he becomes 
momentarily insensible, or a greater degree of insensibility may 
supervene. 

If you see a person getting pale suddenly, have him lie down 
immediately; this will often prevent swooning. If you can get 
to the person before he falls, help to lower him to the recumbent 
position on bed, lounge, floor, or ground, as the case may be. 
Do not put a pillow to the head. Loosen the clothing about the 
neck and waist, secure an abundance of fresh air, fanning him 
if need be. Do not crowd around or allow others to crowd 
around and shut off the air. Smelling salts, or ammonia, 
if handy, may be held to the nostrils, but be careful not 
to burn the nostrils, nor to cause the person to inhale too 
strong ammonia. The temples may be bathed with vinegar 
or brandy. If the patient fails to " come to," sprinkle cold 



Chap. XII] ACCIDENTS AND EMEKGENCIES 145 

water on the face, apply hot bottles to the feet, and send for a 
physician. 

Epileptic Seizures. — Just preceding a convulsion there may be 
a warning scream or cry. Not infrequently a patient has time 
to remove artificial teeth and to lie down before overtaken, but 
often he falls wherever he happens to be, and sometimes sustains 
severe injuries. The face may be pale at first, but usually be- 
comes bluish, red, gray, or livid. The pupils are ordinarily dilated 
and the eyes turned upward. The breathing is usually irregular 
and often stertorous. The patient may froth at the mouth, and 
may bite the tongue in spite of your efforts to prevent it. The 
convulsive movements may be confined to the face or the arms, 
or sometimes the entire body shows contortions that are distress- 
ing to witness. There may be involuntary passage of urine and 
feces. 

It does no good to fuss with epileptics to bring them to con- 
sciousness. The treatment consists in freeing them from lia- 
bility of harm to themselves. When one falls in an epileptic 
fit, leave him where he falls, if no harm is likely to come to him 
there. Loosen the clothing as in syncope. Remove artificial 
teeth beforehand, if the patient gives warning enough, and place 
a rubber cork, or a folded towel, or a knotted handkerchief be- 
tween his teeth to prevent him from biting his tongue. Wipe 
the froth and blood from the mouth, put a pillow under the head, 
and let the patient lie quietly and sleep if he will after the attack. 
If he shows any tendency to strike and bruise himself in his con- 
vulsive movements, it is well to restrain him enough to prevent 
this. 

Sometimes epileptics are excited and dangerous after seizures, 
sometimes just dazed, but oftener they sleep heavily, and on wak- 
ing have no recollection of the convulsion. They are of course to 
be screened from the sight of others if this can be arranged. 

Uremic Convulsions. — Uremic convulsions are due to the fail- 
ure of the kidneys to excrete waste matter from the body. The 
face is usually pale and often waxy looking, there may be swell- 
ing of the eyelids, face, and limbs, the breath may have a 
urinous odor, the pupils are usually dilated. The convulsions 
themselves are difficult to distinguish from those of epilepsy. 



146 NUESING THE INSANE [Chap. XII 

When they are clearly due to uremic poisoning, the treatment 
is to secure active purgation, and to produce sweating by hot 
packs or warm baths, thus calling to the aid of the disabled 
kidneys the excretory function of the skin. Have the patient 
drink copiously of water, and give an enema of normal salt 
solution. 

Hysterical Seizures. — Hysterical seizures are sometimes diffi- 
cult to distinguish from epilepsy. They occur most commonly in 
young girls or in neurotic women in early adult life, but no age is 
exempt, and even men of a certain type may be subject to hysteri- 
cal seizures. A nurse should never use the term hysteria before 
a patient, and she needs to remember that hysteria by no 
means signifies shamming. Some hysterical attacks are under 
the control of the will of the patient, some are entirely beyond 
their control. Sometimes very grotesque and extraordinary con- 
duct takes place. 

In hysterical attacks the patient seldom falls where she would 
injure herself, never bites the tongue, often cries out repeatedly; 
the convulsive movements are of much longer duration than in 
epilepsy (an epileptic attack rarely lasts more than two minutes), 
the patient seldom entirely loses consciousness, she resists attempts 
to open her eyes, the eyes remain sensitive to touch, the pulse is 
usually normal, and the color of the face may be red or pale. 

In general, treat a patient who falls in an hysterical attack much 
as you would one who faints. If you see that the pulse is good, 
and that the patient is made comfortable, and if you are convinced 
that it is hysteria that you are dealing with, it is well not to do 
too much, not to appear to notice the apparent efforts to elicit 
attention and sympathy, but quietly and calmly to say that you 
think the patient will soon be better. All onlookers should of 
course be dismissed at the outset. Loosen the clothing, giving 
free access of air. Sprinkling cold water upon the face may be 
tried. Sometimes pressure in the ovarian regions, or a sharp 
command, will cut short the attack. 

Grave manifestations, and the attacks which especially simu- 
late epilepsy, call for a physician. In a hospital, it is well to call 
a physician anyhow, whether the attack seems to you grave or 
the reverse. 



Chap. XII] ACCIDENTS AND EMEKGENCIES 147 

Apoplexy. — Unconsciousness due to apoplexy is caused by 
rupture or the blocking up of a blood vessel in the brain. The 
patient usually gets dizzy, loses consciousness, and falls. The face 
is flushed, the pulse hard and rather slow, the breathing labored 
and often snoring in character (stertorous) . The nostrils and one or 
both cheeks often puff out at each expiration, the eyes are partly 
closed and may be drawn to one side, the pupils are unequally 
contracted, the limbs relaxed, and one arm and leg, and the 
face often, show some evidence of half-sided paralysis (hemi- 
plegia). Urine and feces may be passed involuntarily during 
the coma. 

Place the patient in a horizontal position, with pillows under 
the head, and cover him lightly. Loosen the clothing. Keep 
him quiet; do not try to rouse him. Do not give stimulants. 
Ice or cold applications may be applied to the head and a hot- 
water bag to the feet. The physician should be summoned 
immediately. 

Sunstroke. — Sunstroke is easily diagnosed because of the symp- 
toms occurring in extremely hot weather and after undue exposure. 
It is ordinarily preceded by severe pain in the head. A similar 
condition may result from an improperly administered hot bath. 

The bodily temperature sometimes rises to alarming degrees 
(105° to 112° F.), the face gets intensely red, the pupils become 
equally contracted, the pulse is full and bounding; later it gets 
weak, and stimulation may be necessary, but that is for the 
physician to decide. 

The treatment is to move the patient to a cool, shaded place, 
remove all unnecessary clothing, apply ice or cold water to the 
head, and sponge the body with cold water till the temperature 
becomes reduced. Instead of sponging, cold water may be 
sprayed over the patient's body from a garden hose, or poured on 
the limbs and chest from dippers or pails. Do not pour it over 
the pit of the stomach. Later, wrap the person in a cold wet 
sheet, as in a cold pack. If the temperature rises again, resume 
the sponging, or other methods used, and the ice applications to 
the head. In a hospital the simplest way is to place the patient 
in a bath of about 70° F., and rub with ice until the temperature 
gets within the normal limits. 



148 NURSING THE INSANE [Chap. XII 

Heat Exhaustion. — Cases of heat exhaustion are those in which 
the exposure results in normal or subnormal temperatures instead 
of high temperatures, as in sunstroke. Such persons are treated 
as one would treat a case of shock. 

Shock. — Unconsciousness due to shock requires prompt treat- 
ment. A reaction must be brought about speedily. Shock may 
follow a variety of conditions, such as fright or other strong 
emotions, operations, accidents, etc. 

In cases of shock the patient is in a collapse; the pulse is weak 
and rapid; the temperature is subnormal, the skin cold and 
clammy; there is extreme pallor, as a rule, and a pinched, drawn 
look about nose and mouth; the breathing is feeble, often sighing 
in character; the eyes are dull; there may be partial or complete 
unconsciousness; nausea and vomiting may occur. 

Put the patient in the recumbent position with the head 
lowered, loosen the clothing, apply hot-water bags or bottles to 
the feet, the arm pits, and the inside of the thighs, taking care 
not to burn or scald the patient. Put a mustard plaster over the 
region of the heart. Give hot black coffee, if the patient can 
swallow, or brandy or whisky in hot milk. Friction of the 
limbs toward the heart may also be tried. When reaction sets 
in after shock, as seen by improvement in pulse and color, stop 
the stimulants. High rectal or hypodermic injections may be 
ordered by the physician, or infusions of normal salt solution 
into the veins, or artificial respiration may need to be resorted 
to if the patient does not rally after the above-mentioned means 
have been tried. 

Blows and Falls on the Head. — Unconsciousness due to blows 
or falls upon the head should be treated by placing the patient 
in a recumbent position with the head elevated, loosening the 
clothing, and securing quiet and darkness, letting the patient 
sleep as long as he can. It can do no harm to place cold appli- 
cations to the head and hot ones to the feet. Hemorrhage re- 
sulting from the injury sustained must, of course, be checked, 
and the wounds dressed antiseptically. 

Asphyxia. — Asphyxia is suspended animation due to failure 
of the blood to become oxygenated. This may come about from 
a variety of causes; but whatever the cause, it is imperative that 



Chap. XII] ACCIDENTS AND EMERGENCIES 149 

respiration be quickly reestablished, or death will soon follow. 
The person must be treated on the spot. Delay is fatal. 

Artificial Respiration. — Artificial respiration, then, is resorted 
to in all emergencies when the person has ceased to breathe. 
As already stated, it may be called for in shock, in asphyxia 
from ether or chloroform or other gases, in narcotic poisoning, 
in drowning, in strangulation, in the new-born infant, and in 
some other conditions. Sylvester's and Hall's methods are both 
to be studied. 

Strangulation from Hanging. — Cut the body down, but do 
not let it fall. Pull the tongue well forward and clear the throat 
of mucus. See that artificial teeth are removed. Remove all 
constriction from the throat. Use Sylvester's method of arti- 
ficial respiration. 

Asphyxia from Anesthetics and Poisonous Gases. — In as- 
phyxia from anesthetics or from poisonous gases, in addition 
to Sylvester's method, see that all the fresh air it is possible to 
supply is furnished to the patient. 

Care of Patient's Choking. — This accident occasionally oc- 
curs among the insane, especially among cases of general pare- 
sis, or in an epileptic taken in a fit while food is in the mouth. 
Such patients should never be allowed to take food except under 
close supervision of the nurse, and very few paretics should be 
allowed to feed themselves even with a nurse close by, as they 
cannot be trusted to do it with safety. Sane persons are liable 
to have a fish bone or some food " go the wrong way " into the 
windpipe instead of into the esophagus, or if it does get into the 
esophagus, it sometimes gets lodged there in such a way as to 
press against the windpipe and cause distress and possibly alarm- 
ing symptoms. Semi-unconscious patients may choke from the 
vomitus getting into the air passage, and struggling patients who 
regurgitate their food during nasal feeding may have this accident 
happen to them. Patients may swallow their artificial teeth, 
or other foreign bodies may get so far back in the pharynx, or 
in the esophagus or the windpipe, as to cause choking. Many 
patients are too demented to show signs of distress, and the first 
intimation you have that anything is wrong is a chance obser- 
vation of the livid face and the ineffectual efforts at breathing. 



150 NURSING THE INSANE [Chap. XII 

Removal of the obstruction is the first step toward relief. 
Whatever is in the mouth and throat can be hooked out by the 
fingers. The forefinger should then be crowded down the throat 
as far as possible to feel for other obstructions, if relief does not 
immediately follow. If some obstruction lodged in the esophagus 
is giving the trouble, it can sometimes be pushed farther down 
to where it is harmless by introducing the feeding tube. 

A piece of bread swallowed may help to carry the trouble- 
some object farther down the esophagus and into the stomach. 
Even if it is some indigestible substance that cannot be softened 
by the fluids in the stomach, no alarm need be felt. Give plenty 
of bread, potatoes, oatmeal, corn-meal pudding, and such foods 
as will have a tendency to incorporate it in the mass and carry it 
along without causing irritation to the alimentary tract. Do 
not give an emetic or a purgative under these conditions. 
If glass has been swallowed, get the patient to swallow cotton if 
you can, as this will help to engage the particles of glass in its 
fibers and so lessen the harm done. A diet similar to that out- 
lined above will protect the mucous membranes of the stomach 
and intestines as much as anything can. Liquids should, of 
course, be prohibited for a time. On no account should an emetic 
or an enema be given. If a foreign body is lodged in the wind- 
pipe, its presence excites coughing, and this will often expel the 
intruder. A blow between the shoulders sometimes helps. A 
child may be taken by the feet and held head downward while 
smart blows are made between the shoulders. It is of no use 
to try artificial respiration, in cases of choking, until the foreign 
body is removed, and after that it is usually not necessary. 

Foreign Bodies in Other Passages. — It sometimes happens that 
foreign bodies are introduced into the urethra, the vagina, or 
the rectum by insane patients, or a thermometer or catheter 
may get broken in these passages and slip beyond the control 
of the nurse. Such an accident should be reported at once to the 
physician. A rubber catheter that is old or in any danger of 
breaking should be discarded, and rectal temperatures should 
rarely be taken in the case of patients who would struggle so 
that such an accident could happen. Patients given to stowing 
away foreign bodies in the vagina need to be frequently ex- 



Chap. XII] ACCIDENTS AND EMERGENCIES 151 

amined, and the vagina cleansed daily with a mild antiseptic 
douche. Enemata should be given frequently to such patients 
as have the habit of crowding things in the rectum. 

Bruises or Contusions. — A bruise or contusion is an injury 
received by direct violence to the soft parts which does not result 
in the breaking of the skin. The signs are pain and swelling 
and discoloration (ecchymosis) of the skin due to oozing of blood 
from the surrounding tissues and to its settling around the 
bruise. Hot applications immediately applied over a consider- 
able surface surrounding the injury, or witch hazel, or alcohol 
and water, relieve pain and favor the absorption of the extrava- 
sated blood. Rubbing the ecchymosed spots with a bland 
ointment like lanolin helps the discoloration to disappear. 
Where great pain is experienced, cloths wet in hot water to 
which a little laudanum has been added, or a lead and opium 
lotion, may give considerable relief. 

Treatment of Wounds. — In the treatment of most wounds the 
first thing to do is to cleanse them thoroughly from all dirt and 
clots with an antiseptic solution. The control of hemorrhage 
in a wound will be considered later. Superficial cuts of any ex- 
tent usually require a few interrupted sutures ; deeper ones may 
require hidden catgut sutures to draw the severed muscles to- 
gether. Deep wounds may also need a drainage tube, or gauze, 
or a few strands of horsehair left in the bottom of the 
wound and so arranged as to protrude from the lower part. 
After being closed, the wound is then dressed antiseptically, 
and, as a rule, may be left undisturbed for several days. Silk 
or wire sutures require removal after a few days, but catgut 
sutures may be allowed to remain, as they become absorbed after 
a short time. Badly lacerated wounds need to have the ragged 
parts removed with a pair of scissors, and the crushed and torn 
parts placed in as natural a position as possible. Some lacerated 
wounds are treated by continuous irrigation. In cleansing all 
wounds, do not touch the wound itself, but squeeze or pour the 
antiseptic stream over them. Scalp wounds need to be cleansed 
thoroughly, and the hair surrounding them cut or shaved before 
the edges are brought together, and held by sutures or straps, 
or dressings, as the case may be. Have a care not to get the cut 



152 NURSING THE INSANE [Chap. XII 

hair into the wounds. Contusions of the scalp swell rapidly, 
often forming blood tumors (hematoma). In cut fingers, bring 
the edges close together, and bandage snugly. Sometimes, when 
a part of a finger or toe is entirely severed, if the parts be cleansed 
and immediately replaced in position and so bound up that firm 
and even pressure is made, there is still a chance of the severed 
member growing again. A thin layer of absorbent cotton held 
down by collodion makes a good dressing for slight wounds. 
Punctured wounds require careful cleansing; splinters or thorns 
must be removed, and the wound kept open so that it will heal 
from below. Some patients put needles under the skin, and some 
introduce them near the heart or lungs, where they are liable to 
cause death. Efforts at their extraction need to be made as 
soon as the injury is known about, as even when introduced 
into parts where their immediate presence could do little harm, 
they are a source of danger, owing to their tendency to travel to 
other and deeper parts of the body. The removal of a fish- 
hook or other barbed instrument should never be attempted 
through the hole at which it entered. It should be pushed all 
the way through and the head broken off. Insane patients 
sometimes bite their fellows or those who are caring for them. 
Severe, lacerated wounds may thus result. Such wounds should 
be squeezed gently under warm water to favor the flow of blood 
at first, and then thoroughly cleansed with antiseptics, as the 
saliva is likely to carry into the wound bacteria that would set up 
a troublesome inflammation. 

Insect Bites, Bee Stings. — Insect bites, bee stings, and the 
like, are relieved by applications of soda, vinegar, ammonia, the 
tincture of ledum, listerine, or peroxide of hydrogen. The sting 
of a wasp or a bee should be removed from the wound by pres- 
sure or tweezers. 

Ivy Poisoning. — The eruption caused by poison ivy is treated 
by applications of an alcoholic lead wash, hyposulphite of soda, 
grindelia, and other preparations, according to the advice of the 
physician. 

Burns and Scalds. — Burns and scalds are injuries or destruc- 
tion of the skin and soft parts due to the application of dry or 
moist heat. When due to dry heat, the injury is called a burn; 



Chap. XII] ACCIDENTS AND EMERGENCIES 153 

when to moist, a scald. They are essentially the same in effect, 
and require the same treatment. They are classified as burns 
or scalds of the first, second, and third degrees, according to the 
depth of the tissues injured. Burns and scalds are dangerous 
in proportion to the extent of the surface affected. Even a super- 
ficial burn may prove fatal through shock if a large part of the 
surface is involved. In young children, especially, a superficial 
burn affecting a third of the body is likely to prove fatal. Ex- 
tensive burns, then, need, in addition to the treatment of the 
lesions themselves, treatment to prevent shock, or to counteract 
it, if it is already present. In cases of shock, guard against re- 
tention of urine by catheterizing if necessary. 

The chief thing in treating burns and scalds is to exclude the 
air, as it is the contact of the air on the raw surfaces that causes 
the intense pain. In superficial burns, where the skin is not 
broken, cooking soda, cornstarch, or flour dusted thickly over 
the affected parts will help to allay the pain. The parts can then 
be covered with moist gauze, lint, or linen, and kept as quiet 
as possible. Or the skin may be protected by painting it over 
with the white of egg, or flexible collodion, or picric acid. If 
blisters have formed, or the epidermis is destroyed, the use of 
soda, flour, etc., is not to be thought of. Blisters should be 
pricked at their most dependent points with a clean needle, 
and the serum absorbed by gauze or cotton sponges, or by clean 
blotting paper. The skin should be kept in place as much as 
possible. The affected parts are then to be painted with picric 
acid if it is obtainable, or covered with liquid or oily applications, 
according to the conveniences you have at command, or, if in a 
hospital, to the most approved treatment there in vogue. Some- 
times gutta percha tissue perforated in several places is laid over 
the burned surface, covered by absorbent cotton, and loosely 
bandaged. Gauze or lint saturated in solutions of soda, or of 
boric acid are often used, and when oil is applied, it is usually 
smeared on pieces of gauze, lint, or old linen, and then covered 
with cotton and bandaged. Carbolized vaseline, table oil, or 
carbolized sweet oil, oxide of zinc ointment, and the like, are 
the applications most commonly used. Carron oil (equal parts 
of limewater and linseed oil) is no longer recommended for burns, 



164 NURSING THE INSANE [Chap. XII 

although formerly much in vogue. For deep burns, continuous 
warm-water baths in which boric acid has been dissolved yield 
good results. In the treatment of burns, one needs to remember 
the great liability to deformity and the necessity for taking pains 
to prevent it as much as possible. In removing clothing, or 
later, dressing, from burned parts, never pull it away; cut with 
scissors as near as possible to the burned surface, and patiently 
soak the adherent material away by squeezing or pouring an 
antiseptic solution against the parts. Expose at one time only 
the part to be then dressed, finishing with each before beginning 
on others. 

Burns produced by strong acids are first treated by bathing with 
some weak alkaline solution, as soda, chalk, ammonia, or even 
scrape the lime from the walls and use that to make a solution 
which will help to neutralize the effects of the acid. Or make 
a paste of common earth and apply if nothing better is at hand. 
Then treat the burn as you would one caused by heat. 

Burns caused by caustic alkalies, such as potash, lime, ammonia, 
lye, should have applications of vinegar, lemon water, or very 
dilute nitric or sulphuric acids made to them to neutralize the 
effects of the alkali, before treating them as you would one 
caused by dry or moist heat. In powder burns, be particular to 
remove the particles of powder with a needle, otherwise per- 
manent spotting of the skin will result. If carbolic acid gets 
spilled on the nurse or patient, immediately saturating the burned 
parts with alcohol will neutralize the effect of the carbolic acid. 

Clothing on Fire. — If a person's clothing gets on fire, he should 
immediately lie down on the floor and roll over and over, keeping 
the mouth shut to avoid inhaling the flames. If he does not lie 
down, he should be thrown down, and a rug, shawl, coat, blanket, 
table cover, or some woolen or even cotton thing should be 
wrapped around him to shut out the air and stifle the flames. 
The doors and windows should be closed; on no account should 
the person rush to them, as the fresh air only makes the flames 
burn the fiercer. In all your efforts, fight the flames away from 
the face first. Pour cold water over the person if that is at hand. 

If a fire occurs in the hospital, it is the nurse's duty to pro- 
vide for the safety of her patients as well as her own. If it is in 



Chap. XII] ACCIDENTS AND EMERGENCIES 155 

some remote part of the institution, so that there is no danger of 
her charges being harmed, she should do as much as possible 
to prevent the spread of the alarm, and should seek to allay the 
fears and fright of those who become disturbed. If there is 
need of vacating the building, the able-bodied patients should be 
marshaled in the center of the hall facing the point of egress; 
every patient should be provided with a blanket; each room, 
closet, bathroom, pantry, or place where a frightened or de- 
mented person could skulk or hide away should be quickly but 
carefully searched to make sure that no person is concealed 
therein, and then the doors should be locked so as to prevent any 
one from going in the rooms later. When all is in readiness and 
the signal is given, the patients should be marched out of the hall, 
either by the door or the fire escape, as the situation demands, 
and they should be conducted to a place of safety, where some one 
is left in charge of them, in order that none may escape or come 
to harm in any way. Helpless patients need to be carried out in 
blankets to a place of safety. 

If the fire drills are regularly and systematically carried out, 
the nurses and patients will be trained to do the right thing, so 
that when real danger threatens, if it ever does, there will be no 
confusion and hurly-burly. Nurses should school themselves 
to take the fire drills so seriously that every detail is attended 
to and insisted upon with almost the earnestness that there 
would be were there a real fire instead of a false alarm. 

When fire is discovered in a building, of course the first thing 
to do is to try to put it out, and to sound the alarm. Closing 
all doors and windows not only helps to prevent the fire from 
spreading, but helps to keep the rooms from getting filled with 
smoke. In most cases it is better to wait for the firemen to 
come, rather than to pitch the furniture out of the windows, or 
allow it to be carried out where it may be stolen or injured by 
water or in other ways. It is sometimes well to remove certain 
articles from threatened rooms and carry them to places of safety, 
but in large cities the fire departments are so prompt and their 
means for handling property are so efficient that, as a rule, it 
is better to trust to their disciplined manner of dealing with these 
emergencies. 



156 NURSING THE INSANE [Chap. XII 

Exposure to Severe Cold. — Persons subjected to intense and 
long-continued cold may suffer merely from chilblains, from frost 
bites, or from grave exhaustion. In fact, chilblains and frost 
bites do not of necessity require long-continued exposure to pro- 
duce them. Demented patients are subject to them on slight 
exposure. Chilblains are painful, they swell and become red- 
dened, and are especially troublesome at night, or whenever 
the parts become much heated. To avoid chilblains, the parts 
should be warmly clad, and one should abstain from going 
directly to a hot stove or a register and suddenly warming the 
hands and feet when they are cold. When chilblains have 
actually formed, painting them with iodine every other day will 
relieve the itching, and bathing the affected parts every night 
and morning with tepid water, in which some nitric acid is 
dissolved (15 drops to a pint of water), or with cold water and 
ammonia, will afford some relief. If neglected, ulcers some- 
times form, and will then need to be treated accordingly. Frost 
bites often take place without the sufferer knowing about them. 
As soon as noticed, the part should be rubbed with ice, or snow, 
or cold water should be applied, the object being to restore 
circulation to the part gradually so as not to cause sloughing. 
To this end the person should not be taken immediately into a 
warm room. As soon as friction and cold applications have 
resulted in the return of sensation and color to the part (it having 
been cold, pale, and often stiff before), the rubbing may be 
discontinued, but cold applications should be kept up for a 
time. If the effects of severe cold have resulted still more seri- 
ously, the person may be in a state of exhaustion bordering on 
coma, or may be quite comatose. He should be kept in a cool 
atmosphere, the clothing removed, and the body rubbed with 
ice or snow or cold water, later with pieces of flannel, furs, or the 
hand. The temperature must be gradually raised. He must 
not be allowed to yield to the drowsiness that is overtaking him; 
at the same time efforts must be made to conserve his strength 
as much as possible. Aromatic ammonia guardedly held at the 
nostrils will help to revive him, and nourishment, with or without 
stimulants, according to the severity of the case, should be given 
as soon as he can swallow. Beef tea, hot milk, black coffee, are 



Chap. XII] ACCIDENTS AND EMERGENCIES 157 

perhaps the best foods to administer. It may be necessary to 
give stimulants by the rectum, if the patient cannot swallow 
As reaction begins to take place, the body may be protected by 
warm coverings, but the person should not be subjected to a 
heated atmosphere for some time. 

Hemorrhage. — Hemorrhages may be external or internal. 
When external, they are easily detected, but when internal or when 
they occur in wounds much covered by dressings, they may only 
be discovered by the following constitutional symptoms : pallor, 
anxious face, dilated pupils, pinched nose, coldness of extremities, 
clammy skin, feeble, rapid pulse, shallow and sighing respiration, 
subnormal temperature, restlessness, perhaps thirst, dimness 
of vision, ringing in the ears, difficulty in speaking, later, uncon- 
sciousness and death, if the patient does not rally from the shock. 
Fainting has a tendency to check the hemorrhage, as the arrest 
to the flow of blood through the system affords an opportunity 
for the blood to coagulate, and so stop the mouths of the bleed- 
ing vessels. 

Do not give stimulants in shock from hemorrhage unless so 
ordered by the physician, except when, in the absence of the 
physician, there is danger of heart failure. 

Nature herself will often check hemorrhage in a short time. 
The veins, because of the character of their walls, and the absence 
of propelling force to the blood, quickly close, as a rule, and the 
clot that forms and plugs them arrests the hemorrhage. The 
arteries are more elastic than the veins; when they are cut, their 
muscular coats contract, lessening the caliber of the vessels, and 
drawing the arteries back into the tissues. This contraction and 
retraction help to form a clot which, if not too quickly dislodged, 
checks the hemorrhage. Exposing the injured ends of the artery 
to the air favors the formation of a clot, and elevation of the 
injured part, so as to reduce the force of the blood sent to it, 
also helps nature to arrest the hemorrhage. If these simple 
means fail, other artificial means must be tried. 

Artificial Means for Arresting Hemorrhage. — The artificial 
means used to check hemorrhage are: (1) elevating the limb or 
part; (2) pressure directly on or above the bleeding vessel; (3) 
flexion of padded joint near the point of hemorrhage; (4) tying 



158 NURSING THE INSANE [Chap. XII 

(ligation) of the bleeding vessel ; (5) application of heat or cold, 
or remedies to aid the coagulation of the blood (astringents or 
styptics) ; (6) cauterization ; and (7) twisting or torsion of the 
bleeding vessel. 

Elevation of a part should be tried with other means whenever 
practicable. Pressure on a bleeding artery must be made at the 
bleeding point or above the wound, or between the wound and 
the heart. If the bleeding vessel is too deep to be reached, plug 
the wound with a graduated compress, fastened firmly over the 
part. Bleeding can be easily controlled if the fingers can get 
to the artery and if the vessel is so situated that pressure can be 
made upon it against a bony surface. If the artery cannot be 
reached, pressure upon some of the branches leading to it will 
help to control the hemorrhage. 

If a large artery has been severed, and medical aid is not at 
hand, it may be necessary for the one making pressure on the 
artery to be relieved by another, until a physician can be sum- 
moned; or a tourniquet may be improvised. Do not relax the 
pressure to see if bleeding has stopped. 

To control bleeding in the temporal artery make pressure in 
front of the ear, just above the point where the lower jaw can 
be felt moving in the act of chewing. Severe hemorrhage in the 
head and upper part of the neck may be controlled by burying 
the thumb and ringers deeply in the neck just in front of the 
conspicuous muscle which runs diagonally across the side of 
the neck. Patients often sustain hemorrhages in the arteries 
at the wrist by thrusting their hands through window panes, 
often for the purpose of getting pieces of glass with which to cut 
their throats. Persistent bleeding in the palm of the hand is best 
checked by placing some hard substance in the palm (stone, apple, 
lemon), having the person grasp it tightly, then bandaging the 
closed hand, holding the arm high above the head. Hemor- 
rhage in the fore-arm can be checked by placing a pad at the 
bend of the elbow, bending the arm and bandaging in that posi- 
tion. The femoral artery can be felt in the middle of the groin at 
the top of the thigh. Hemorrhages in the thighs and legs may be 
treated by a tourniquet, or by flexion of the hip and knee joints. 

Hemorrhage from a vein is controlled by removing everything 



Chap. XII] ACCIDENTS AND EMERGENCIES 159 

between the wound and the heart that would retard the flow of 
blood (garters, etc.), by elevating the limb, and by applying a 
firm compress directly to the wound. If bleeding is due to 
varicose veins of the legs, apply a bandage over a compress, 
beginning at the toes and going up a short distance above the 
seat of bleeding. If bleeding is from the scalp, a compress and 
bandage will arrest it. Extensive cuts require sutures. Wounds 
of the face bleed freely, but are usually easily controlled by 
pressure or hot applications. Care should be taken to bring the 
wounded parts close together so as to prevent unsightly scars, 
and sutures are often necessary to this end. As has been said 
heretofore, it is important that all wounds should be treated, an- 
tiseptically, and one needs to remember, in the efforts to staunch 
the hemorrhage, not to touch the wounds with unclean hands, 
nor to let soiled materials come in contact with wounded sur- 
faces. 

Cold and Hot Applications and Styptics. — Cold applications 
are made in the form of pounded ice and ice compresses, and 
are often employed to check capillary hemorrhage. Extremely 
hot applications (125° to 130° F.) have a stimulating as well as 
a styptic effect. (Warm water favors instead of checking hem- 
orrhage.) Other styptics besides cold and heat are MonseFs 
solution of iron, perchloride of iron, alum, tannic acid, vinegar, 
and common salt. 

Ligating or tying the ends of bleeding vessels, as well as tor- 
sion or twisting them, and cauterizing them, are means for 
arresting hemorrhage that are for the physician to apply. 

Cut Throat. — Patients may make long cuts on the neck and 
do very little real injury, or they may make a small stabbing 
wound, injuring a large vessel, and may die almost instantly. 
They may cut the windpipe (trachea) instead of the vessels, 
and they may wound the epiglottis or the esophagus in their 
attempts to sever arteries. The windpipe can be felt in the 
front of the neck in the middle line. The large arteries and the 
veins of the neck are on each side of it, some superficially and 
some deeply located. If the windpipe has been cut, there is 
danger of suffocation from blood getting into it. Placing the 
patient on his side or face will help to prevent this. There is 



160 NURSING THE INSANE [Chap. XII 

also danger of pneumonia from much cold air gaining ready 
access to the lungs. Keeping light, moist, hot flannels over the 
wound helps to prevent this complication. The operations of 
tracheotomy or intubation may have to be performed in some of 
these injuries to the trachea. If the epiglottis or the esophagus 
is wounded, the food may have to be administered by rectum. 

When any of the large arteries of the neck are severed, the hem- 
orrhage is alarming, and will prove fatal unless instant relief is 
obtained. Firm pressure must be made upon the bleeding 
arteries between the wound and the heart, and maintained 
until a physician can be summoned and the ends of the vessels 
ligated. Have the patient sit with head bent forward and the 
chin pressed against the chest while pressure with the thumb 
and fingers is kept up on the injured vessel. Large veins like 
the jugulars should be compressed both above and below the 
wound for two reasons — to prevent bleeding from both ends, 
and to prevent the entrance of air which would cause sudden 
death. 

Extreme care needs to be exercised in suicidal cases after 
wounds have been dressed, as such patients will usually watch 
their chance to remove dressings and reopen wounds. They 
will often feign sleep, will say how sorry they are that they tried 
anything so wicked, and will resort to all sorts of deceit to put 
the nurse off guard so that they may yet make a success of the 
thing in which they have been thwarted. Suicidal persons are 
very fertile in their plans for obtaining means and opportunity 
for self-injury. One desperate patient I have in mind had been 
thwarted in several attempts at self-destruction by the nurses 
getting to her as soon as they heard the crash of the broken 
window panes, before she could get t time to cut her throat. 
Accordingly, she laid her next plan very carefully. Just before 
breaking a window pane she prepared the bare floor with soap- 
suds so that the nurses, on running to rescue her as they heard 
the broken glass, slipped, floundered, and some of them fell 
on the slippery floor, but luckily one succeeded in reaching her 
before the cut in the neck went deep enough to cause anything 
but a capillary hemorrhage. 

Hemorrhage from the Mouth may be from the teeth, throat, 



Chap. XII] ACCIDENTS AND EMERGENCIES 161 

stomach, or lungs. If severe bleeding follows the extraction of 
a tooth, quickly replace the tooth if you can, or apply a com- 
press, wet with a solution of alum, to the bleeding cavity. 

Hemorrhage from the Stomach (hematemesis) consists of dark 
blood, often looking like coffee grounds, which is vomited up, 
usually mixed with particles of food, and often accompanied 
by distress in the stomach. It is usually followed by tarry 
stools. 

Hemorrhage from the Lungs (hemoptysis) is bright red, frothy 
because of its admixture of air, is usually coughed up, is mixed 
sometimes with mucus, and is often accompanied by distress 
in breathing. 

In any of these cases place the patient on the back, with head 
and shoulders elevated, give plenty of fresh air, let bits of ice 
dissolve on the tongue. In hemoptysis, equal parts of vinegar 
and water, or lemon juice and water, may be swallowed. Salt 
(i teaspoonful) was formerly recommended, but the danger of 
its causing vomiting makes its use of doubtful value. Place 
a light ice bag on the chest in hemorrhage from the lungs, and 
over the pit of the stomach when the blood comes from that 
organ. Do not allow the patient to speak, to move, or to swallow 
food, if the hemorrhage is from the lungs and is of considerable 
quantity. Do not give warm drinks in either of these conditions. 
Seek to allay anxiety by soothing words and an encouraging 
manner. Summon a physician at once. Hemoptysis, if alarm- 
ing, may sometimes be arrested by cutting off the venous return 
from the limbs long enough to diminish the force of the blood, 
and so permit clots to form. This is done by placing temporary 
ligatures around one arm and the opposite thigh, and leaving 
them in place for about five minutes, then removing them and 
placing them on the corresponding limbs for the same length 
of time; this procedure may be repeated till hemorrhage ceases. 

Hemorrhage from piles (hemorrhoids) may be checked by ice- 
water enemata, or pieces of ice placed in the rectum. 

Nosebleed (epistaxis) is often profuse and difficult to check, 
but is rarely dangerous. It is usually preceded by a full feeling 
in the head, and some vertigo, and a congested face. The head 
should be kept upright, the chin elevated, the arm on the affected 



162 NURSING THE INSANE [Chap. XII 

side raised above the head, the clothing loosened about the neck. 
Pressure may be made near the nostrils, and cold applications 
to the forehead, the back of the neck, and the bridge of the nose. 
Avoid blowing the nose, as it disturbs the formation of clots. 
If these means fail to give relief, a nasal douche of ice water, 
or a strong salt solution (1 dram of salt to 4 ounces of water) 
may be used, or this solution may be sniffed into the nostrils, 
or in its stead equal parts of vinegar and cold water may be 
tried. Plugging the nares may need to be resorted to if the 
hemorrhage proves obstinate and exhausting. 

In all cases of hemorrhage, the blood passed should be saved 
for the inspection of the physician. 

Treatment of Poisoning. — The first thing to do in most 
cases of poisoning is to provoke vomiting. Do this by tickling 
the throat, or running the finger down the throat, or by giving 
an emetic. The emetics usually at hand in every house are warm 
water and salt (2 tablespoonfuls of salt to J pint of water), 
and mustard and water (1 tablespoonful of mustard to J pint 
of water). Other emetics are zinc sulphate (10 to 20 gr. in J 
glass of water), copper sulphate (2 to 5 gr.), tartar emetic 
(1 to 2 gr.), fluid extract of ipecac (15 to 20 minims), or a hypo- 
dermic injection of apomorphia (■£$ to -J gr.). If emetics fail 
to produce vomiting, use a stomach pump, unless an irritant 
or corrosive poison has been taken. 

Save the vomitus for the inspection of the physician, and note 
if the odor of any drug can be detected either in the breath or 
in the vomited matter. The urine should also be saved for 
analysis. 

Send for a physician immediately on learning of the poison- 
ing, but do not wait for his arrival before acting. Learn, if you 
can, what poison or poisons have been taken. A certain patient 
I have in mind was brought to the hospital suffering from 
poisoning, and it was afterward learned that she had that day 
and the day previous taken listerine, laudanum, valerian, ether, 
cologne, whisky, chloroform liniment, and Belladonna oint- 
ment; at least, she confessed, after resuscitation, to having taken 
these, and the symptoms which she showed led us to suspect 
that she had taken an overdose of opium also. If one can 



Chap. XII] ACCIDENTS AND EMERGENCIES 163 

determine positively what poison has been taken, the proper 
antidote (a medicine to counteract the effect of the poison) is 
to be administered, usually after vomiting has been produced. 
After vomiting takes place, it is well to cause the person to 
drink freely of milk, and in most cases it is wise to give an 
enema. 

For corrosive and irritant poisons, emetics are, as a rule, best 
omitted. These poisons act so quickly on the tissues, causing 
severe distress and ulceration, that the most relief will be ob- 
tained by giving the chemical antidote to neutralize the effects 
of the poison, followed by soothing (demulcent) drinks to relieve 
the distress as much as possible. The demulcents are milk, 
white of egg, gum-arabic water, flaxseed tea, olive oil, gruel, 
boiled starch, etc. 

For narcotic poisoning, besides emesis, antidotes, and treat- 
ment for stimulating the heart and for restoring the respiration, 
may need to be resorted to. Strong coffee, atropine, strychnine, 
whisky, are used as heart stimulants. In threatened paralysis 
of the respiratory movements, dash hot and cold water alter- 
nately on the chest, dilate the opening to the rectum, and try 
artificial respiration if necessary. Keep the patient awake, but 
do not exhaust him by walking him about. Striking the cheeks, 
the buttocks, and the soles of the feet vigorously will help to 
keep him awake. 

When you are positive that an acid poison has been taken, 
give some alkali for an antidote — magnesia, cooking soda, lime- 
water, chalk and water, ammonia water (^ teaspoonful to a 
glass of water), soapy water, even tooth powder quickly stirred 
in water. 

When you know that a strong alkali has been taken, such as 
caustic potash or soda, ammonia, soft soap, an acid must be 
used as an antidote — vinegar and water, cider, lemon juice, 
or some of the other acids much diluted. Later, sweet oil may 
be given with soothing effect. 

Strangulated Hernia. — A hernia is a protrusion of some 
internal organ or part from its natural cavity. Commonly 
speaking, by a hernia we mean some part of the intestine pro- 
truding through an opening in the abdominal walls. This is 



164 NURSING THE INSANE [Chap. XII 

also called a rupture. We speak of a hernia as reducible when its 
contents can be readily put back; when they cannot, as irre- 
ducible. A hernia is often supported artificially by an appliance 
called a truss. A hernia may become inflamed, obstructed, 
or strangulated. Strangulated hernia is a very serious condi- 
tion. By this we mean that the hernia becomes constricted so 
that its circulation is cut off; it is then in danger of gangrene 
unless the constriction is relieved. 

Signs of Strangulated Hernia. — The tumor becomes more 
tense, and tender; there is severe abdominal pain; the usual 
impulse in it noted on coughing is absent; vomiting of food, 
then of bile, and later of feces takes place; there is obstinate 
constipation, loss of strength, a rapid, feeble pulse, later, gan- 
grene and collapse. 

If the hernia cannot be replaced by manipulation (taxis), an 
operation (herniotomy) is necessary to save life. 

Fractures. — The signs of a fracture are pain and tenderness, 
inability to move the part naturally, but unusual mobility when 
handled, deformity or displacement, crepitus, or a grating sound 
and sensation experienced by rubbing the broken ends together, 
swelling and ecchymosis. There is often inequality in the 
length of the sound and the injured limb. 

Management of Fracture. — The nurse's duty concerning a 
fracture is to put the patient in as comfortable a position as 
possible and keep him quiet until the arrival of the physician. 
By injudicious handling or motion a simple fracture may be 
converted into a compound or a complicated one, as when the 
sharp end of a broken rib may be made to protrude through the 
skin or to pierce the lung. Violent patients may have to be 
held to keep them from thus injuring themselves. 

If the clothing needs to be removed, take that from the sound 
side first, then rip or cut it away from the injured side, on no 
account subjecting the patient to the manipulations necessary 
to remove it in the ordinary way. If a foot, ankle, or leg be 
injured, it is important to remove the boot before swelling be- 
comes extreme. Steady the injured limb as much as possible 
in removing the boot. If it cannot be removed easily, or if 
great pain is experienced, cut the boot at the seam. Remove 



Chap. XII] ACCIDENTS AND EMEKGENCIES 165 

garters, unfasten suspenders, and in all work around the patient 
work quietly and with a view to sparing needless movement 
and pain. 

Moving an Injured Person. — When necessary to move the 
patient to some distance, before the fracture can be reduced, 
improvised splints and an improvised stretcher have to be arranged. 
A man's overcoat buttoned, with the sleeves put inside, and 
long poles passed along the sides, does very well for a stretcher, 
or a blanket or a strong shawl rolled on poles will answer, or 
a broad fence board, or a window shutter from the nearest 
house. The point to be remembered is, in lifting the patient, 
lift him so that there is no unnecessary movement or jar, and 
have some one person assigned to lift and care for the injured 
limb after it has already been supported in as natural and as 
comfortable a position as possible by such splints as you are 
able to arrange. 

For a fractured clavicle the patient should be placed flat on his 
back and a pad put in the armpit, the arm then bound to the 
side, the fore-arm placed diagonally across the chest. Fractured 
fore-arms should have splints placed on the back and front of 
the fore-arm from the elbow joint to the palm of the hand, and 
the arm carried in a broad handkerchief sling. The sleeve of 
a dress or of a man's coat, or the skirt of a coat, may be made 
to serve as a sling. If the arm is fractured, it should be bound 
tightly to the side of the chest. Fractured ribs require a broad 
body bandage applied tightly enough to prevent motion and to 
restrict deep breathing. There is danger of the broken ribs 
piercing the pleura or the lung. Spitting of blood is likely to 
follow this injury. 

Fractures of the skull may render the person insensible. Vomit- 
ing, pallor, and feeble breathing may take place, or there may 
be confusion or unconsciousness. Bleeding from the mouth, 
nose, or ears may occur. Insuring darkness and absolute quiet, 
and immediately summoning the physician, are the chief things 
the nurse can do. Do not move the patient in such cases unless 
absolutely necessary. In cases where there is injury to the 
brain, due to fragments of bone pressing on the brain, an opera- 
tion (trephining) for lifting these fragments may have to be 



166 NURSING THE INSANE [Chap. XII 

performed. Before this operation, that part of the scalp sur- 
rounding the injured portion requires shaving and antiseptic 
cleansing. 

If an injured person is removed from the place of accident 
and placed in bed before the arrival of the physician, always 
bear in mind the necessity for as little movement as possible. 
Remove the clothing, and, as a rule, render the part as clean as 
you can, treating all wounds antiseptically if you possibly can. 
By attending to these matters, you avoid unnecessary delay, and 
the physician can then begin on the work that strictly belongs 
to him as soon as he reaches the bedside. If, however, a com- 
pound fracture exists, beyond efforts at checking hemorrhage, 
it is better not to interfere, but to let the physician direct the 
treatment from the start. In most cases of injury the clothing 
will need to be arranged so that the sound side may be compared 
with the injured one. In injuries to hip and thighs, place a 
towel over the genitals and lift the clothing to the waist line. 
The nurse needs to get in readiness, if they are obtainable, 
cotton and gauze bandages (3 to 6 inches wide), lint, absorbent 
cotton, adhesive plaster, plaster of Paris, some antiseptic solu- 
tion (bichloride of mercury, 1 to 1000), plenty of hot water, 
towels, and sheets, and newspapers to protect the floor if plaster 
of Paris is used. 

Dislocations. — The signs of dislocations are impairment of 
the ordinary motion of the joint, deformity, swelling, discolora- 
tion, and severe pain. 

Dislocations are reduced by manipulation or by extension. 
Sometimes it is necessary to use a general anesthetic 'to over- 
come the muscular resistance before the parts can be put back 
in place. After the dislocation is reduced, the parts are held in 
place by firm bandaging until the strained or torn ligaments 
become strong again. 

The nurse should summon aid as quickly as she can in these 
injuries, meanwhile maintaining hot applications to the injured 
parts. 

Treatment of Sprains. — Hot applications, showering with hot 
water, or placing the part in hot water, the temperature of which 
is gradually elevated to the toleration point, and entire rest for 



Chap. XII] ACCIDENTS AND EMERGENCIES 167 

a week at least, with bandaging, are the most approved means 
of treatment for sprains. An opium and lead lotion often aids 
in reducing the swelling and tenderness. When these have 
subsided, passive motions and massage, if carefully applied, may 
be used. If the ankle is sprained, and the patient must be on 
his feet, strap the ankle with adhesive plaster, or use some 
other supporting dressing. 



CHAPTER XIII 

CARE OF SPECIAL MEDICAL CASES 

The insane are subject to infectious and contagious diseases 
and to general diseases as well as the sane. The care necessary 
to prevent the spread of contagion needs to be even greater than 
when nursing the sane. 

Prompt and effectual isolation in infectious and contagious 
cases is imperative. The room should be stripped of all super- 
fluous furniture, and those caring for the patient should avoid 
as much as possible mingling with others of the household. 
Utensils, dishes, bed and body linen used for the patient should 
be kept exclusively for him, unused portions of food should be 
burned, likewise withered flowers that have been in the room, 
and scrupulous attention to disinfection should be rigorously 
maintained. Thorough ventilation of the room is at all times 
important. The bare floors should be cleaned daily, avoiding 
the scattering of dust, and should be sprinkled with a disin- 
fectant. The door should be kept closed, and outside of it 
should hang a wide sheet kept wet with a carbolic acid solution 
(lto40). 

The bed and body linen needs to be soaked one hour in car- 
bolic solution (1 to 40) or bichloride of mercury (1 to 1000) and 
wrapped in clean disinfectant sprinkled sheets before being sent 
to the laundry. 

All discharges, sputum, vomited matter, urine, feces, blood, 
should be received in vessels containing some disinfectant; 
more is then to be poured on them, and the disinfectant thor- 
oughly mixed with the excreta. The closed vessel should then 
be carried away and the mass allowed to stand, two hours for 
feces, and ten minutes for urine, before being emptied, burned, 
or buried. 

168 



Chap. XIII] CARE OF SPECIAL MEDICAL CASES 169 

Drains, sinks, water closets, and outdoor closets, should 
receive applications of chloride of lime several times daily. 
All dishes and utensils should be disinfected and boiled after 
contamination. 

The patient's body should receive the strictest care as to 
cleanliness, and also certain parts should be immediately cleansed 
after the passage of excreta, and bathed in an antiseptic solution 
(1 to 5000 bichloride of mercury). 

In the eruptive fevers the scales of skin may be prevented 
from falling about by smearing the skin with some antiseptic 
ointment. Secretions from the nose and throat may be received 
in soft rags or paper napkins, and immediately burned. The 
swabs used in cleansing the patient's mouth, and the rags used 
to cleanse the genitals and the anus, must be thoroughly dis- 
infected and burned, and the nurse must thoroughly disinfect 
her hands each time after they have come in contact with any 
of the discharges from the patient. 

The nurse should wear a cotton gown and should cover her 
gown completely, when temporarily mingling with others of the 
household, or when going out for exercise, with an outside wrap 
kept in an adjoining room. She should exercise especial care 
to disinfect her hands before partaking of food and should 
avoid taking the patient's breath, as well as unnecessary contact 
with the discharges. Especial attention must be given to her 
own health, as to food, sleep, and exercise. 

When the patient is convalescent, the contaminated rooms 
must be thoroughly fumigated with sulphur or formaldehyde. 
The bedding and clothing may be disinfected by steam. 

The nurse should thoroughly disinfect all her clothing that 
has been subject to contamination, and both patient and nurse 
should have a cleansing tub bath followed by a sponge bath of 
bichloride of mercury (1 to 3000), and entirely fresh clothing, 
before leaving the isolation quarters. 

In death from infectious diseases, the body should be sponged 
with bichloride of mercury (1 to 1000), the nostrils, mouth, 
vagina, and rectum plugged with strong bichloride saturated cot- 
ton, the body wrapped in a sheet saturated with a strong disin- 
fectant, placed in an air-tight casket, and given a speedy burial. 



170 NURSING THE INSANE [Chap. XIII 

Treatment of Fevers. — The treatment of all fevers should 
be directed toward neutralizing the effects of the poison devel- 
oped in the system by the action of the bacilli; toward promot- 
ing the elimination of waste products; toward reducing the 
temperature; and toward maintaining the nutrition. Stimu- 
lation may need to be resorted to, but only on advice of the 
physician. Medicines are of secondary importance; suitable 
food, in suitable quantities, and regularly administered, and 
treatment directed toward the conservation of the patient's 
strength, are the main reliance in fevers, and especially in 
typhoid. Enemata, possibly purgatives, generous supplies of 
drinking water, packs, and baths, are the means used to aid 
the excretory functions. 

The room should be kept cool, from 60° to 70° F. Both too 
bright a room and darkness should be avoided. The night 
nurse should see that the night lamp is shaded on the side toward 
the patient. Too heavy bed coverings should be avoided. If 
abdominal tenderness appears, the clothing may be kept from 
weighing on the patient by using a bed cradle. Discard feather 
pillows in fever cases if you can secure hair pillows instead. 
Fresh linen needs to be supplied often, and the clothing and 
sheets must be kept dry, clean, smooth, and free from crumbs. 
Extra pains must be taken to guard against bed sores starting. 
This is all the more difficult, as it is important, if intestinal 
symptoms predominate, that the patient lie quietly on the back 
with as little exertion or movement as possible. When the 
physician gives permission, the patient's position in bed may be 
altered a little, and his back propped up with pillows or sand 
bags, and so relieve pressure upon the most dependent parts. 

The diet must be liquid, such as milk, beef juices, egg water, 
koumys, or buttermilk, as ordered. Milk, either cold, warm, 
or boiled, is considered the safest and best diet as a rule. About 
two quarts should be taken daily, it being given regularly in six- 
ounce feedings every two hours. It is important that it be 
sipped slowly. If a patient is sleeping rest fully, unless so ordered 
by the physician, do not waken him to give him his nourishment 
just on the hour, but exhausted cases in a stupor should be 
wakened, as they usually drop back again very quickly. Vichy 



Chap. XIII] CAEE OF SPECIAL MEDICAL CASES 171 

or limewater may be added to the milk, or a little coffee to 
flavor it, if permitted. The physician usually orders the milk 
peptonized, sterilized, or Pasteurized. 

The drinking water should be boiled for fifteen minutes and 
then cooled by being packed in ice, but not by having ice put 
in it. Toast water and grape juice are grateful additions to the 
monotonous diet. Food should be given by means of feeding 
cups or glass tubes if possible. 

Careful bedside charts should be kept by the nurse. 

As a rule the liquid diet should be continued at least a week 
after the temperature has become normal. Later, soups, broths 
with rice, milk toast, meat jellies, soft eggs, junket, sago, well- 
cooked gruels, may be given, as allowed by the physician. 

The appetite of a patient in the latter part of typhoid is usually 
voracious, and the nurse will have to be very watchful that no 
mischievous interference on the part of the friends, and no 
wheedling or connivance of the patient is allowed to endanger 
the patient's life in this respect. For indiscretions in diet are 
liable to produce hemorrhage and perforation of the intestines. 
Likewise exertion and movement, until sanctioned by the 
physician, should on no account be permitted by the nurse, 
however much the patient may urge the matter. 

The mouth, teeth, and tongue should be frequently cleansed 
by swabbing with glycerine and lemon juice, boric acid solution, 
or listerine, especially after the patient has taken milk. 

Daily movements of the bowels are as a rule secured byenemata. 
The bed pan is to be used until the physician gives express per- 
mission to use the commode. The anus and surrounding parts 
should be washed in an antiseptic solution after each stool. The 
presence of blood or of milk curds in the stools should be reported. 

It may be necessary to cease giving nourishment if intestinal 
hemorrhage threatens. Ice coils are used in these cases. The 
patient may require stimulation. A transfusion of hot normal 
salt solution may be employed. 

For distension of the abdomen, high saline enemata often 
give relief, or turpentine stupes or enemata. 

If affusions, packs, cold sponging, or baths are prescribed, 
remember that each step must be so planned as to save the patient 



172 NURSING THE INSANE [Chap. XIII 

every bit of unnecessary strain or exertion. If a tub bath is 
given, the patient must be lifted in and out of the tub. Some- 
times as many as five or six baths a day are necessary to reduce 
the temperature, to quiet the delirium, to steady the heart, 
and to overcome the insomnia. Baths or some other hydriatric 
measure are usually ordered if the temperature goes above 
103° F. Do not reduce the temperature below 100°, as there 
would then be danger of collapse. 

Secure as much sleep to your patient as you can. Remember 
to guard delirious patients with extreme care, not relaxing sur- 
veillance for an instant. 

Cerebro-spinal Meningitis. — The treatment of cerebro-spinal 
meningitis should aim to secure good nutrition, free bowels, 
thorough ventilation, darkness, and quiet. Noise, light, and even 
the lightest touch are likely to increase the spasms. Ice bags 
to the head and spine help to relieve the pain. Although the 
disease is not very communicable, the patient should be isolated. 

Influenza (La Grippe). — In the treatment of influenza isola- 
tion is advisable. At the beginning a hot bath and hot lemonade 
are given to induce sweating, and such remedies as are prescribed 
by the physician. The patient should go to bed and stay there 
till the temperature is normal, and the conspicuous symptoms 
have disappeared. Carelessness in this respect often gives rise 
to a long train of troubles that may follow in the wake of this 
disease — catarrhal pneumonia, heart and kidney complications, 
neurasthenic symptoms. The strength should be maintained by 
liquid diet. Frequent hot baths give relief, in the nervous form 
especially. Ice bags to the head and spine relieve pain and in- 
somnia. Antiseptic gargles should be used freely. 

Mumps. — The treatment of mumps calls for isolation. Rest 
in bed during the acute symptoms is important. An abundance 
of fresh air should be continually supplied. Hot fomentations to 
the swollen and painful regions, liquid food, attention to the 
excretory functions, avoidance of draughts, and the use of 
antiseptic mouth washes and gargles, are the nursing measures 
especially to be adopted. 

Vaccination. — Vaccination is usually performed on the outer 
side and upper part of the arm, or on the under side of the calf^ 



Chap. XIII] CARE OF SPECIAL MEDICAL CASES 173 

or on the front part of the thigh. The skin all around the part 
chosen should be thoroughly cleansed with soap and water, then 
washed with a solution of bichloride of mercury (1 to 5000), and 
rinsed with sterile water or alcohol. With a sterile needle a 
small square of the epidermis or scarf skin is slightly scratched, 
care being taken not to draw blood. The vaccine virus is then 
rubbed into the denuded surface with a sterile toothpick which 
usually comes with the vaccination outfit. The surface, after 
being allowed to dry, is covered with a light compress of sterile 
gauze. 

If vaccination "takes," a papule appears on the third day 
which later becomes a vesicle surrounded by a red area. About 
the eighth day, pus forms, and the place gets very painful ; then 
the inflammation subsides gradually, and about the twenty-first 
day the scab falls, leaving the characteristic white scar. Some- 
times a rise in temperature, with headaches, nausea, and other 
constitutional symptoms may appear about the time that the 
vaccination is " working." In some cases, the lymph glands 
near by become enlarged, and the pain and swelling are quite 
severe. These inconveniences are, however, greatly to be pre- 
ferred to the disease from which vaccination gives protection, 
or if not that, it greatly lessens its severity if smallpox does 
attack one. 

Measles. — In the treatment of measles, isolation is of the 
utmost importance. Thorough ventilation must be maintained, 
and the room kept at about 65° F. The eyes must be protected 
from strong light. Cleansing of the eyes, nose, and throat, and 
the use of eye drops, gargles, and sprays are important points 
in the nursing, in addition to the usual fever nursing. The 
quarantine should be maintained for at least three weeks, and 
careful fumigation and disinfection secured after recovery. 

Diphtheria. — The strictest isolation is imperative. Early 
administration of the diphtheria antitoxin is now considered 
the best and safest means of treatment. In most instances 
the administration of antitoxin is followed by a lessening 
of all the symptoms — the fever, the restlessness, the swell- 
ing, and the disappearance of the membrane. Antitoxin is 
injected in the thigh, or buttocks, or between the shoulders, 



174 NURSING THE INSANE [Chap. XIII 

after cleansing the part with soap and water, scrubbing with 
an antiseptic solution, and rinsing with sterile water. The 
syringe and needle are sterilized and the serum slowly injected. 
Certain symptoms may follow the use of antitoxin — an erup- 
tion similar to scarlatina may appear, the joints may swell and 
become painful, and the temperature run very high. These 
effects are not dangerous, but often cause consternation. The 
nurse should receive an immunizing dose (100 to 500 units), and 
a full dose if the throat should begin to be sore. After four 
weeks' time, if still exposed to the contagion, the immunizing 
dose should be repeated. 

The nursing is to be directed toward maintaining the patient's 
strength by diet, an abundance of fresh air, the avoidance of all 
unnecessary exertion, strict attention to the bowels and bladder, 
and to careful watching to guard against complications that 
may arise. 

Guarding against taking the patient's breath or letting him 
cough in the face or on the clothing of the nurse are important 
precautions, and frequent spraying of the nurse's nose and 
throat as well as of the patient's is needful. 

Distress in breathing is treated by inhalations of steam or 
medicated vapors, or, if necessary, by the operations of intu- 
bation, or of tracheotomy. 

A patient should not be released from quarantine till all 
symptoms of the disease have disappeared and till repeated 
examinations have shown that there are no longer any diphtheria 
germs in the throat. 

Erysipelas. — Quarantine the erysipelas patient and keep him 
in bed. Give plenty of water to drink, and light, nutritious diet. 
Follow the usual directions for fever nursing. If the inflam- 
mation has started from a wound, or if wounds or abrasions 
exist, they are to be treated antiseptically. Soothing applications 
to the inflamed areas are made according to the advice of the 
physician. The nurse needs to protect her hands by covering 
any scratches or abrasions that may be on them. She should 
never go from a case of erysipelas to take charge of a surgical 
or an obstetrical case. 

Dysentery. — Absolute quiet in bed, milk diet, or arrowroot, 



Chap. XIII] CARE OF SPECIAL MEDICAL CASES 175 

burnt flour and milk, egg albumen, beef juice, boiled water to 
drink, starch enemata, flushings of the colon, hot fomentations 
to the abdomen, ice to the anus to relieve straining — these are 
the chief things to remember in nursing cases of dysentery. The 
patient should of course use a bed pan, and the stools should 
be carefully disinfected. A flannel binder should be worn dur- 
ing the disease and for months after. 

Rheumatic Fever. — Inflammatory rheumatism is another 
name for this painful disease; it is supposed to be of bacterial 
origin. The patient must be kept in bed. It is important 
to avoid draughts, and to keep the temperature from 68° to 
70° F. Flannel nightgowns and undervests, and flannel sheets 
are to be preferred. The affected joints should be kept 
wrapped in cotton and should be put in a semiflexed position. 
The diet should be liquid, chiefly of milk. Water in abundance, 
lemonade, oatmeal and barley water are useful adjuncts. Pain 
is relieved by the application of ice bags (a flannel cloth inter- 
vening) or of hot water bags, or by various local applications that 
may be prescribed. All unnecessary movement and jarring 
must be prevented; the heart must be watched for signs of 
trouble, and the patient must not be allowed to exert himself 
or to get out of bed until the temperature has been normal for at 
least a week, and even then not without the permission of the 
physician. 

Pneumonia. — The patient should be kept in bed with 
head and shoulders raised on pillows. An abundance of fresh 
air must be supplied night and day; the room should be 
kept at 70° F. Absolute quiet and as little talking as possible 
must be enjoined. Regular and sufficient nourishment, chiefly 
milk and raw eggs, is all-important. The food should be given 
by means of a glass rod or a feeding cup. After the crisis, 
semisolid food may be given, gradually increasing to regular 
diet. Stimulants are given, only on the advice of the physician. 
The bowels must be kept free by enemata if necessary. The 
sputum should be disinfected. Delirious patients must be con- 
stantly watched to prevent exertion likely to cause heart failure. 
Cotton jackets to the chest covered with oiled silk, poultices, 
antiphlogistine jackets, and other applications, are used accord- 



176 NURSING THE INSANE [Chap. XIII 

ing to the advice of the physician. The patient should not be 
allowed out of bed till at least ten days after the crisis. 

Tuberculosis. — Isolation of tubercular cases is of the utmost 
importance if there is cough and expectoration. It is best that 
the patient, if capable of cooperating, should know that he has 
the disease, so that he can be trained to safeguard others from 
the constant danger they would be in but for his care in regard 
to the sputum. 

The sputum of phthisical persons contains bacilli in enormous 
numbers, and when dried, these germs mix with the dust, float in 
the air, and become a widespread source of danger. Tuberculous 
sputum must never be allowed to dry. It must either be received 
into rags or paper and immediately disinfected and burned, or 
into sputum cups containing a disinfectant that will kill the 
germs, or at least into cups containing water that will keep it 
moist until disinfection can be accomplished later. A 1 to 10 
carbolic acid solution, or a 1 to 2000 bichloride of mercury, may 
be kept in the cups and cuspidores, except when accessible to 
suicidal patients. Receptacles should be emptied and cleaned 
frequently and boiled every twenty-four hours. If a fire is 
within easy reach, it is perhaps best to use paper in the sputum 
cups and burn the paper immediately after use. 

The care of the tubercular patient may be summed up in a 
few words — the prevention of the spread of the disease, supply- 
ing an abundance of fresh air continuously, teaching the patient 
to breathe properly, furnishing sufficient quantities of nourish- 
ing and easily digested food, suitable clothing, bathing him 
frequently, and in securing moderate exercise in some cases 
and complete rest for others, and very little if any internal 
medication. 

The nurse for the tubercular insane has to contend with extra 
difficulties, for in many cases she can get no cooperation on the 
part of the patient. Some patients will swallow their sputum, 
and others will expectorate wherever they wish — on the floor, 
bedding, behind radiators, in their handkerchiefs, or on their 
petticoats, in the faces of the attendants, and of other patients, 
and so on. Some will rub the expectorated matter in their hair 
or beards. Mischievous and suicidal patients have to be watched 



Chap. XIII] CARE OF SPECIAL MEDICAL CASES 177 

to prevent them from drinking the disinfectants in the sputum 
cups. Male patients should be kept clean shaven. Unclean 
patients need frequent baths and shampoos, and their faces and 
hands washed many times a day. All scratches, cuts, abrasions, 
on either patients or nurses, should be treated antiseptically and 
kept covered till healed. The nurse should be particular not to 
stand in front of the patients when they are coughing or sneez- 
ing, as the minute particles of moisture expelled may contain 
multitudes of bacilli. The clothing and stools should be carefully 
disinfected. 

Many patients who seem incorrigible at first as to the use of 
sputum cups, can, by patient training and encouragement, be 
persuaded to cooperate fairly well, and extra care on the part 
of the nurses must supplement this partial cooperation on the part 
of the patients. If the nurse keeps her own health up to par 
by hygienic living, and observes the rules for ventilation, and for 
the frequent disinfection of the ward, and the proper disposal 
of sputum, her duties in the tubercular wards are not attended 
with the dangers that exist on other wards where perhaps an 
unrecognized case may be endangering the entire ward. 

The weight and appetite of each patient must be carefully 
watched; charts recording the temperature course, and that of 
the pulse and respiration, should be kept; the character of the 
cough and of the sputum noted; the frequency and severity of 
night sweats reported. Temperatures should be regularly taken 
morning and evening, the evening temperature not earlier than 
5.30 p.m. 

Patients who are able should spend as much time out of doors 
as possible, not walking about so as to exhaust themselves, but 
suitably clad, sitting or reclining in easy chairs, or lying on cots. 
Beds should be wheeled before open windows, or on balconies or 
verandas whenever practicable. With sufficient coverings and 
hot-water bottles, bricks, or soapstones, patients may be kept 
out of doors in very severe weather without danger or dis- 
comfort. 

In cases where there is marked fever, the patient should be 
kept in bed so to conserve his strength as much as possible. 

Patients capable of understanding instruction should be 



178 NURSING THE INSANE [Chap. XIII 

taught deep breathing and encouraged to practice it in the open 
air or before open windows several times a day for ten or fifteen 
minutes at a time. Sponge baths should be given daily, and 
attention to the bowels and kidneys should be a routine matter. 
Patients having night sweats should be given a glass of hot milk 
at about 4 a.m. regularly, and should be dried with hot towels and 
put in dry clothing at the termination of the sweats. 

If there is distress in breathing, inhalations of moist air often 
afford relief, or hanging moist towels before a hot-air register 
helps a little. The temperature of the room should be kept 
from 70° to 75° F. as a rule. 

If cod liver oil or emulsions are administered, they should be 
given in small doses at first and gradually increased as the 
patient can tolerate them. 

Tubercular patients should receive small quantities of easily 
digested food often and regularly. 

Tonsilitis. — Hot-water applications or poultices give relief 
in the suppurative form and hot- water gargles help also. Iced 
compresses and ice bags are used in the follicular form of ton- 
silitis; also applications of bicarbonate of soda applied by 
the finger to the tonsils. When the abscess is opened, or if 
it bursts, the patient should be instructed, if awake, not to 
swallow the contents. Antiseptic gargles should be used after 
the rupture of the abscess. Liquid nourishment is called for 
until the swelling and soreness subside. Ice cream is a welcome 
addition to the diet. Bits of ice are given in the early stages, 
and inhalation of steam if breathing is difficult. 

Enteritis. — The treatment consists in securing fasting in the 
acute conditions, later, in administering the proper diet, in 
maintaining rest in bed, and in flushing the intestines after 
stools. Flannel binders should be worn in chronic cases, and 
the patients need to avoid getting damp or chilled. Careful in- 
spection and reporting of the stools, and their disinfection, are 
important in the nursing of either acute or chronic cases. 

Appendicitis. — The treatment for appendicitis is both medi- 
cal and surgical — absolute rest, liquid diet, and ice bags to 
relieve pain. If an abscess is discovered, or if the symptoms 
persist for three days, an operation for the removal of the ap- 



Chap. XIII] CAEE OF SPECIAL MEDICAL CASES 179 

pendix is usually advisable. The nursing then is similar to that 
after any abdominal operation. 

Intestinal Obstruction. — The treatment varies according to 
the cause of the obstruction. Lavage of the stomach may be 
called for to relieve the distension and the intestinal movement. 
Thorough enemata are usually given under the direction of 
the physician, sometimes under an anesthetic. In giving an 
enema the nurse should note if the tube meets obstruction, 
and at what point; whether the fluid is returned immediately 
or is long retained; whether it is colored by fecal matter, and 
what the character is of that which comes away. She needs to 
remember that in fecal impaction, causing nearly complete 
intestinal obstruction, there is often diarrhea, the loose stool 
tunneling its way past the hard fecal masses. Vomiting and 
hiccough are relieved to some extent by cracked ice. Turpen- 
tine stupes are sometimes ordered for distension. Surgical 
interference may be called for. 

Bronchitis. — Rest in bed with head and shoulders elevated, 
liquid diet, free action of bowels and kidneys, abundance of 
fresh air, inhalations of medicated vapor, hot fomentations to 
the chest, hot drinks, and hot foot baths are the nursing 
measures for cases of bronchitis. 

Asthma. — One with this disease needs an abundance of 
fresh air; the patient should be allowed to assume the position 
that affords the greatest relief; hot foot baths, hot drinks, es- 
pecially coffee, hot poultices over the chest, honey during the 
attack, whiffs of chloroform, inhalations of nitrite of amyl, or 
of burning niter paper, or of other drugs, pastilles, and cigarettes, 
are among the means of relief that are tried for these sufferers. 

Pleurisy. — The treatment is rest in bed and rest of the 
affected side as much as possible. Talking should be avoided. 
Lying on the painful side and strapping that side with ad- 
hesive straps help in diminishing movement. There should 
be an abundance of fresh air, and light, nourishing diet. Ice 
bags afford some relief to pain. Where the effusion is abun- 
dant, restricting the amount of liquid food, using purgatives, 
and stimulating the skin and kidneys to freer action, are be- 
lieved by some to be of material benefit. 



180 NURSING THE INSANE [Chap. XIII 

Endocarditis. — The treatment is rest in bed and nourishing 
diet. Rest during the primary disease is probably as much 
of a preventive measure as we have at command. The dis- 
eases that give rise to this condition are chiefly rheumatic 
fever, tonsilitis, pneumonia, and scarlet fever. Often the first 
intimation that the patient has developed this lesion of the 
heart is when the physician discovers a soft blowing murmur 
there during the course of some of the acute diseases. Persons 
with these valvular lesions can with care live many years and 
suffer only from time to time from the effects of the defective 
valves. When the heart fails to compensate properly toward 
the end of their lives, dropsy, congestion of the lungs, and ex- 
treme difficulty in breathing are the symptoms to be expected. 

Chronic Valvular Lesions of the Heart. — The treatment is 
to relieve the dropsy by medicines, or, if necessary, by punc- 
turing the edematous legs and bandaging them with Canton 
flannel bandages. The distress in breathing is alleviated to 
some extent by suitably arranged head rests, as the patient 
is obliged to rest and even to sleep in the sitting posture. Have 
a care that the head rest is broad enough to support the head 
when it falls over on the side. Tapping the chest may be neces- 
sary. Antiseptic cleansing of the skin should precede this, as 
well as all operations for dropsy. An ice bag over the region of 
the heart sometimes lessens the palpitation. The diet must be 
so regulated as to prohibit starchy foods and all others that 
would cause flatulence. Vomiting is allayed by bits of ice in the 
mouth, effervescing drinks, and a mustard plaster over the heart. 
The sleeplessness, starting in sleep, and frightful dreams can be 
helped by remedies, and also by the soothing offices of the nurse. 
The bowels and kidneys need to be kept free. It is often neces- 
sary to diminish the quantity of liquids taken; four ounces at a 
time is sufficient allowance when nausea and distaste for food 
are marked. Stimulants are given only when prescribed by the 
physician. 

The treatment for Palpitation of the Heart is to be directed 
toward quieting the emotional excitement which gives rise to 
this symptom in so many nervous persons. Digestive disturb- 
ances, excessive use of tobacco, and other stimulants are often 



Chap. XIII] CARE OF SPECIAL MEDICAL CASES 181 

at the bottom of this condition. It may also be the result of 
organic troubles of the heart. Whatever the cause, seek to 
allay the apprehension. Moderate exercise often gives marked 
relief in some cases, others require rest in bed. Hot baths 
should be avoided, but tepid baths and cold sponging are bene- 
ficial. Regulation of the diet and sleep are all-important. 
Starchy foods and heavy evening meals are to be prohibited. 

The treatment of Angina Pectoris is to so regulate the patient's 
life as to avoid all unnecessary strain, indigestible food, and meals 
at late hours. During the paroxysms, the inhalations of amyl 
nitrite or a few whiffs of chloroform give relief. 

Uremia and Chronic Bright's Disease. — The treatment of 
Uremia and of Chronic Bright's Disease may be considered to- 
gether. Saline purgatives, copious draughts of water, and warm 
baths are the chief means used to favor the action of the kid- 
neys. Inhalations of chloroform are given during convulsions. 

Persons with chronic Bright's disease should regulate their 
lives so as to throw the least possible strain upon the heart, ar- 
teries, and kidneys. Moderate exercise, freedom from worry, 
regular bowels, active skin and kidneys, copious water drink- 
ing, as a rule, total abstinence in regard to alcohol, light and 
nourishing diet, but little meat, and plenty of milk, are the means 
to be used to this end. If the heart is seriously affected also, the 
patient should drink water in small quantities. 

Diabetes. — The treatment is to restrict the diet as to starchy 
foods and those containing much sugar. The diabetic patient 
should lead a quiet life, free from strain and worry. It is 
necessary to keep the skin active by daily tepid or cool 
bathing, and the bowels free, and to avoid getting chilled. A 
troublesome itching that is common in this condition is 
relieved by lotions of hyposulphite of soda, or by ichthyol and 
lanolin ointment. The thirst for water may be indulged, and 
milk, buttermilk, tea, coffee, cocoa, lemonade, and fruit juices 
sweetened with saccharine tablets, are allowed. Only food easy 
of digestion should be taken. Bread made from gluten flour, or 
almond or cocoanut biscuits should be substituted for all other 
kinds of bread. Sugar and syrups are prohibited. The patient 
may take clear soups, fish, sea food, meats (except liver), lettuce, 



182 NURSING THE INSANE [Chap. XIII 

celery, tomatoes, spinach, asparagus, cucumbers, pickles, and 
most fruits. Articles especially to be avoided are thick soups, 
ordinary breadstuffs, hominy, rice, tapioca, macaroni, pota- 
toes, turnips, cabbage, parsnips, squashes, beets, beans, peas, 
corn, beers, and wines. 



CHAPTER XIV 

SOME POINTS IN SURGICAL NURSING OF THE INSANE 

In discussing briefly some points in surgical nursing, more 
particularly of the insane, I shall presuppose that the nurse 
already understands something of the germ theory of certain 
diseases, that she realizes that we are surrounded with minute 
vegetable organisms invisible to the naked eye, and that it is 
because of these bacteria that we adopt the modern methods of 
antiseptic surgery. Bacteria are in the air, the water, the soil, 
our food, and our bodies. Some bacteria cause disease, others 
fermentation, still others putrefaction. Bacteria multiply rap- 
idly under the conditions of moisture and a suitable tempera- 
ture (85° to 104° F.). A temperature below 65° F. retards the 
growth, but even freezing does not destroy them. Most bacteria 
are killed if subjected for two or three minutes to a temperature 
above 160° F., but some require 284° F., and three hours' ex- 
posure. Some bacteria are destroyed by sunlight. All bac- 
teria are not disease-producing. Some have important duties 
to perform in the body. Germs are embedded in our skins so 
firmly that long-continued and vigorous scrubbing and the use 
of disinfectants are necessary procedures before undertaking 
surgical operations. We cannot hope to get all of them off by 
scrubbing, and so we use disinfectants to kill the germs, or anti- 
septics to render them as harmless as possible. Our mouths 
are full of germs. The very germ that is responsible for the 
infection of pneumonia is believed to be habitually present in 
the mouth of almost every healthy person. It is only when 
these organisms gain entrance to the lungs, and the person is not 
strong enough to resist their destructive work there, that pneu- 
monia develops. 

The disease-producing bacteria enter the body through abra- 

183 



184 NURSING THE INSANE [Chap. XIV 

sions in the skin and mucous membranes, through the alimen- 
tary and respiratory tracts, and through wounds. The pregnant 
woman may infect the fetus through the placenta. Through the 
activity of bacteria, certain poisons called toxins are developed 
in the body, and it depends upon the power of the body to re- 
sist these poisons whether the disease shall conquer the patient 
or the patient conquer the disease. Bacteria leave the body 
through the skin, lungs, kidneys, or bowels. Hence the necessity 
for using disinfectants and antiseptics in scarlet fever when the 
skin is peeling, and in smallpox when the crusts are drying, in 
pneumonia and phthisis to disinfect the sputum, and in typhoid 
fever to render innocuous the urine and the stools. 

The chief disinfecting agents are heat and chemicals. When we 
use heat, the process is spoken of as sterilization; when chemic 
agents are used, as disinfection. Heat, and especially fire, is by 
far the most thorough means at command for disposing of in- 
fected articles, such as playthings, books, and furnishings that 
have been contaminated, and also of sputum and feces. In sur- 
gical work, fire is not generally used to sterilize instruments, 
as it destroys their temper, but heat in the form of hot air, moist 
air (steam), and boiling water, is one of our most reliable germi- 
cidal aids. 

Hot air or baking should continue one hour at a temperature 
of 300° F. Boiling water (212° F.) destroys germs in from two 
to four minutes. Sterilization by steam is the accepted means 
for clothing, blankets, carpets, curtains, mattresses, pillows, 
towels, dressings, instruments, and so on. Moist heat at 140° F. 
for ten minutes will destroy most of the disease-producing germs. 

The most commonly used chemical disinfectants are bichloride 
of mercury (corrosive sublimate), carbolic acid, and other coal- 
tar products, such as creolin, and lysol, formaldehyde, perman- 
ganate of potash, hydrogen peroxide, boric acid, iodoform, aris- 
tol, alcohol, chlorinated lime and sodium carbonate combined, 
ichthyol, sterilized vinegar, bicarbonate of soda. 

Normal salt solution is much employed in aseptic surgery as 
preferable to sterilized water, specially for irrigation, for injec- 
tions in case of shock, in diabetic and uremic coma, in hemor- 
rhage, in gynecology, and the like. It is so called because it 



Chap. XIV] SURGICAL NURSING OF THE INSANE 185 

resembles so closely the degree of alkalinity of the blood. It is 
made by dissolving prepared tablets in one quart of sterile water, 
or roughly, one teaspoonful of salt to one pint of water. When 
hypodermic injections of the saline solution are used, they are 
made on the chest, abdomen, between the shoulders, or on the 
arm or thigh. From a pint to two quarts of the solution at a 
temperature of 100° F. are injected. The skin should be ster- 
ilized and all the appliances used. 

Bandaging. — Bandages are strips of fabrics — gauze, flannel, 
muslin, rubber — used to keep dressings and applications in 
place, to make compression, to support and protect parts, and 
to prevent motion. The first requisite concerning a bandage 
is that it shall fulfill the especial purposes for which it is ap- 
plied ; next, that it shall be comfortable ; and lastly, that it shall 
be without wrinkles and look well. Excessive tightness must 
be avoided; on the other hand, one must remember the ten- 
dency of bandages to become loosened after being worn awhile, 
and so must apply them snugly and with even pressure. In 
bandaging the extremities, the ringers and toes are to be left 
uncovered, so as to watch the circulation in these parts. If 
they are cold, numb, swollen, or livid, the bandage should be 
loosened. 

In applying a bandage, fix it by two or three overlapping turns 
around a part, holding the outer surface of the roller next the 
skin. Bandage from below upwards and from within outwards, 
over the front of the limb. Use firm, even pressure throughout. 
Let each succeeding turn overlap two thirds of the preceding one. 
Keep the margins parallel, and let the crossings and reverses be in 
line and on the outer side of the limb. Do not make reverses 
over bony prominences. Fasten the end of the bandage by a 
safety pin or a stitch or two, or by tearing the ends in two strips 
for a little way, reversing and tying about the part. In remov- 
ing a bandage, roll it loosely in the hand as it is unwound, so as 
to keep it all together in your hand. 

Surgical Technique. — The surgical nurse needs to acquaint 
herself with the accepted methods of preparing the operating 
room, the dressings, sutures, and instruments, and all other 
appliances. She needs to know how to prepare the patient for 



186 NURSING THE INSANE [Chap. XIV 

the various operations, how to assist at each operation in what- 
ever capacity assigned her, and how to care for the patient 
properly after operations through to convalescence. She needs 
to acquaint herself with the various steps of the operations at 
which she is likely to be called upon to assist; to be thoroughly 
familiar with the names and uses of the various instruments; 
and to know what ones are likely to be called for at a given 
operation, and the order in which they are to be handed. These 
necessary instructions are to be learned from books and lec- 
tures, and from practical instruction in the operating room. 

The anesthetics in most common use are nitrous oxide, ether, 
chloroform, ethyl bromide, and ethyl chloride. 

Preparation for General Anesthesia. — A patient should be 
allowed no solid food for twelve hours previous to taking the 
anesthetic; beef tea, coffee, or tea may be given up to within 
four hours of the operation, after that nothing but water. In- 
sane patients need to be watched with great care in this respect, 
as some will often steal or get other patients to steal food for 
them unless prevented. This abstinence concerning food is to 
prevent vomiting during the inhalation of the anesthetic — an 
undesirable happening for several reasons; the vomiting of solid 
food may endanger the patient's life, solid particles getting into 
the trachea or getting lodged in the throat so that suffocation 
might result; or a pneumonia may follow as a secondary result; 
furthermore, vomiting delays the operation and renders the 
operator's task unnecessarily difficult, and it may come at a 
stage in the operation when delay would be especially unfor- 
tunate. In emergency cases, if a person has to be anesthetized 
soon after a meal, it is often desirable to wash out the stomach 
before administering the anesthetic. 

The bowels must be evacuated by enemata persisted in until 
you get a clear return, or by cathartics, if ordered; the bladder 
by urination, or, if necessary, by catheterization. The patient 
should be instructed to urinate just before going to the anesthe- 
tizing room, even if he urinated shortly before that time. 

Sometimes the physician orders whisky or brandy by the mouth, 
or a hypodermic injection of morphia one half hour before the 
administration of the anesthetic. 



Chap. XIV] SURGICAL NURSING OF THE INSANE 187 

The clothing should be clean, light, and warm, and free from 
constrictions about throat, waist, or elsewhere. The physician 
will examine the urine and the heart before deciding upon giving 
an anesthetic. 

Just previous to the administration of any anesthetic, the 
mouth must be thoroughly examined for artificial teeth, to- 
bacco, or any foreign substance that may be stowed away in 
the mouth. The word of a patient must not be taken in this 
respect. Some persons will deny having false teeth, and some 
are too dull or too stupid to tell the truth; sometimes there 
are only a few false teeth, perhaps only one, and not realizing 
why the question is asked, the patient will deny having any. 
On no account must this duty of examining the mouth be 
neglected, as the teeth or other foreign objects are likely to 
be swallowed, or to cause strangling, when unconsciousness 
supervenes. 

The patient should be anesthetized in a room apart from the 
operating room, so as to be spared every possible sight and thought 
of the ordeal to which he is to be subjected. He should be spared 
the sight of the surgeon and his assistants in operating gowns, 
and the sound of the rattling of instruments. A few cheerful 
reassuring words by the nurse and the physician will help to 
soothe the very natural excitement and apprehension attendant 
upon the operation. Beyond this talk and the necessary direc- 
tions of the physician, strict silence should be maintained. The 
reprehensible practice of some physicians and nurses of chatting 
during the administration of an anesthetic cannot be too strongly 
condemned. It is an affair of grave moment to the patient, unless 
he is too demented to understand about it; physicians and nurses 
should imagine themselves in the place of the one on the table 
long enough to reflect how they would feel to be lying there help- 
less, and trusting their very lives to persons who are perhaps 
chatting about some festivities of the night before, or what 
operations are on for the next day, or what will be done in these 
operations to-day in case such and such conditions are met with. 
Or even if the talk is quiet and dignified and unobjectionable in 
itself, it should still not be allowed unless really necessary, as it 
increases the time necessary to get the patient under the anes- 



188 NURSING THE INSANE [Chap. XIV 

thetic. It must be remembered, too, that patients can often 
hear what is being said when they are unable to make any sign. 

The means for resuscitation, and the things likely to be needed 
from start to finish, should be close at hand upon a small stand 
at the head of the anesthetizing table, and within easy reach of 
the anesthetist — ether, chloroform, an ether cone, a chloroform 
mask, a chloroform dropper, vaseline or oil to anoint the face 
around the nose and mouth, a sponge holder, a tongue forceps, 
a mouth wedge and gag, anesthetizing stethoscope, gauze or 
cotton swabs, a pus basin, two hypodermic syringes in working 
order, one charged with -£$ gr. of strychnine, a tumbler of sterile 
water, 2 oz. of vinegar, 2 oz. alcohol (95%), 4 oz. whisky or 
brandy (ammonia, digitalis, atropine, and amyl nitrite are usually 
provided also), several towels, and perhaps an electric battery, 
and an oxygen inhaling apparatus. 

For most operations the patient should lie on the back, with the 
head on a level with the body or on a small, flat pillow. The body 
is warmly covered with blankets, and the arms are so arranged 
on the chest that the radial pulse may be easily felt. A towel 
should be spread under the chin. 

On rare occasions it falls to the lot of the nurse to give the 
anesthetic, but as a rule her duties in the anesthetizing room are 
confined to watching the patient, to restraining him if struggling 
takes place, to holding the hand and calming nervous patients, 
to watching the pulse, to managing the head, towels, and basin, 
if vomiting occurs, and freeing the mouth and throat from food 
and mucus, to rendering any help she can to the anesthetist, to 
crossing the arms and pinning the sleeves to the nightgown 
before moving the patient to the operating table, and to watch- 
ing the patient carefully until the return of consciousness. She 
should not restrain slight restless movements, but must be alert 
to help when help is necessary. It is the nurse's duty during the 
operation to see that the position of the arms and legs is uncon- 
strained, and also when coming out from anesthesia. The arms 
must not be allowed to hang for even the short time of transfer- 
ence from anesthetizing table to operating table, and the pa- 
tient's body should be kept in a horizontal position in making 
the transfer. 



Chap. XIV] SURGICAL NURSING OF THE INSANE 189 

If at any time during the administration of an anesthetic 
respiration shows signs of being suspended, and speaking to the 
patient or pressing upon the chest does not serve to establish 
breathing, the foot end of the table will need to be elevated; 
these means failing, the tongue must be pulled forward, the jaws 
lifted, the mouth gag inserted, and perhaps heart stimulants, 
Sylvester's method of artificial respiration, and the Faradic 
battery called into use. 

If vomiting occurs at any time, the mask must be removed, 
the head turned to one side, and on a level below the body, 
to prevent the entrance of the vomitus into the air passages. 
The mouth should be cleared of food and mucus before replacing 
the mask. If there seems to be an accumulation of much mucus 
in the pharynx, this must be removed by swabbing out the throat 
with a sponge firmly fastened in a pair of long forceps. 

The danger signals during anesthesia are dilated pupils, irregu- 
lar or arrested breathing, blueness of lips and face, swelling of 
veins in forehead and temples, and at first a slow, later a rapid, 
almost imperceptible pulse. 

Patients coming out from ether or chloroform must not be left 
alone an instant. They are usually transferred to their beds while 
partly unconscious, the clean bed being previously warmed by 
hot bottles, which are later to be placed at the patient's feet, 
under the arms, and between the thighs, if the operation has been 
prolonged and attended with any sign of shock. 

The placing of gauze wet in vinegar over mouth and nose, 
after wiping away the vaseline, and before the patient is removed 
from the operating table, is a favorite procedure with some who 
think that it lessens nausea and retching. Cold compresses 
to the throat help to control vomiting. After abdominal opera- 
tions, during retching and vomiting, the abdomen should be 
supported by the nurse. 

Remember that patients often hear what is said when they 
are coming out from an anesthetic while they appear to be still 
unconscious. Neither the operation nor their condition should 
be discussed in their presence. When only half conscious from 
the anesthetic, patients sometimes need to be urged to " spit 
out," if they do not seem inclined to expel the vomitus that 
comes up in the mouth. 



190 NURSING THE INSANE [Chap. XIV 

Nourishment is not allowed for twelve hours as a rule. Phy- 
sicians differ greatly in what they will allow after anesthetics, 
especially after certain operations. Some allow sips of plain 
hot water, or hot soda water, others pellets of ice, others black 
coffee, or strong tea, and others will not allow even a sip of water 
for many hours (36 to 48 hours), especially after abdominal 
operations. Some will allow the patient to rinse the mouth 
frequently and spew out the rinsings. None will object to fre- 
quent moistening of the lips and tongue with ice wrapped in 
gauze, to relieve the distressing dryness of the tongue. Be 
careful to touch the fore part of the tongue only, or you will be 
likely to nauseate the patient. Patients get desperate when 
thirst after anesthetics is extreme; some, unless watched, will 
try to drink the water from the hot-water bottles, or will attempt 
to get out of bed and get at that in the toilet pitcher. One 
pint of saline solution given slowly as a rectal douche, helps 
to relieve intense thirst. 

The room of the patient should be kept about 70° F., and an 
abundance of fresh air continuously supplied. The bed should 
be accessible from both sides, the eyes shielded from light, and 
yet the face in sufficiently strong light that pallor or other signs 
of hemorrhage may be detected. A basin should be close at 
hand but out of the patient's sight except when in use. 

Patients often complain of severe backache after operations. 
Rubbing the back affords relief in some cases ; in others, placing 
a small pillow under the back, or, if the nature of the case will 
admit of it, turning the patient partly on the side and supporting 
the back with pillows, will be successful. Abdominal pain may 
be due to the operation, to gas in the abdomen, to too tight 
binders, or to a distended bladder. Heat is acceptable when 
pain is due to manipulations of the abdominal organs; abdominal 
tension is relieved by a roller placed under the knees ; the escape 
of gas may in some cases be helped by turpentine stupes, or by 
the insertion of the long rectal tube; a distended bladder should 
be evacuated, and uncomfortable dressings made comfortable, 
if possible, by nicking them, if too tight, or possibly by reapply- 
ing, but only on permission of the surgeon. Nervous patients, 
alcoholic cases, and drug habitues often show considerable 



Chap. XIV] SURGICAL NURSING OF THE INSANE 191 

nervous excitement and restlessness which can sometimes be 
alleviated by massage; others are greatly helped by a little 
judicious sympathy and assurance. Headache is often relieved 
by cold compresses or an ice bag applied to the head. 

Insane patients need especial supervision in coming out from 
an anesthetic, and after certain operations, until healing takes 
place, to guard against any chance removal of dressings or dis- 
turbance and contamination of them, or any exertion that would 
be prejudicial to the patient. Vigilance must be exercised at 
every hour of day and night in certain cases. It is sometimes 
necessary to apply a camisole or a safety sheet to prevent self- 
injury, or struggling, or other exertion that would be harmful. 
The quantity of urine should be noted and reported after ether- 
ization, because of the prejudicial effects of ether on the kidneys 
in some patients. 

The local anesthetics most commonly in use are cocaine, eucaine 
ethyl chloride, alcohol, ether, crushed ice, or crushed ice mixed 
with salt. 

In preparing insane patients for operations in addition to ob- 
serving the most thorough surgical technique, the nurse must 
bear in mind the mischievous and meddlesome tendencies of 
many of her patients, and must be constantly on her guard 
to prevent patients from interfering with preparations after 
they have been made. 

Preparation begins the day previous to the one set for the 
operation; in some instances several days in advance. The 
nurse who makes the preparation must be surgically clean and 
have a nurse to assist her who handles articles not aseptic. 
Purgatives are sometimes given. An enema persisted in until 
a clear return is obtained is necessary the day before the opera- 
tion, and it is also well to give another the day of the operation. 
A specimen of urine is sent to the laboratory. The hair is washed 
and the scalp thoroughly shampooed. A general tub bath is 
given in hot water; plenty of soap and a vigorous scrubbing 
and rubbing are to be employed if the patient's condition admits 
of it. Be especially careful in scrubbing the abdomen in cases 
of appendicitis. Next, the part to be operated on, and a large 
area around it, is to be shaved and scrubbed with green soap; 



192 NURSING THE INSANE [Chap. XIV 

the razor should be held nearly at right angles to the part; the 
object in shaving is not only to remove the hair but also to scrape 
off the epidermis; the surface should then be rinsed with sterile 
water, then scrubbed with lime and soda, and thoroughly rinsed 
again. (A green soap poultice may be applied and left on for 
about two hours to soften the epidermis.) The surface is then 
thoroughly rinsed with sterile water; then with alcohol and ether, 
and the parts covered with a moist dressing of bichloride of 
mercury (1 to 3000), or a carbolic solution (1 to 80); the sterile 
dressing, previously prepared, is then applied and securely 
fastened until the time of operation. (Just previous to the 
operation, this sterile dressing is removed, and the operative site 
washed, usually with alcohol and ether, before the surgeon begins 
his work.) 

It is well to remember that copious drinking of water the day 
previous to the operation helps to prevent shock. Cleanse the 
teeth and mouth with boric acid solution, and have the patient 
cleanse the nostrils by inhalations, both the day before and the 
day of the event. 

In cases where the abdomen is to be opened, the preparation 
is usually begun three days in advance, with daily warm baths, 
light, nutritious diet, purgatives and daily enemata, and daily 
vaginal douches. The shaving in these cases extends from the 
breasts halfway to the knees, especial care being taken with the 
genitals and the umbilicus. The vaginal cleansing is first of 
soap and water, then rinsing with sterile water followed by a 
douche of 1 to 4000 bichloride of mercury, after which the vagina 
is packed with a strip of iodoform gauze or plain sterile gauze, 
which is removed one hour before the operation, followed by 
another bichloride douche and a mopping out of the vagina with 
alcohol before repacking. It must be remembered that if the 
bowels move after the vaginal preparation has been made, the 
vagina must then receive another douche, and the external parts 
again be thoroughly cleansed. In curettage and some other 
minor operations, many surgeons do not require shaving of the 
vulva; in other cases the hair is required to be removed from 
the labia and perineum only, while in still others it must be 
removed from the upper part of the vulva also. After the vaginal 



Chap. XIV] SUEGICAL NUKSING OF THE INSANE 193 

cleansing, the vulva, which has been previously shaved, is cov- 
ered with an antiseptic dressing kept moist till the time of the 
operation. 

Sterile dressings are removed on the operating table by using 
bandage scissors, care being taken to cut well over to the sides, 
so that the scissors do not come in contact with the surface 
rendered aseptic. 

The patient should have on fresh clothing — an undervest, if 
the nature of the operation admits of it, a nightgown opened 
behind, and stockings. No jewelry should be worn. The hair, 
if long and abundant, should be braided in two braids well 
toward the sides of the head, or fastened firmly around the 
head if the operation is to be on the neck. The hair is to be 
covered with a sterile towel, or a Capelline bandage may be 
applied. 

For minor operations, and especially emergency cases, the general 
bath and shampoo may be omitted, and a rapid but thorough 
preparation made on short notice by thoroughly scrubbing the 
operative site with green soap and hot water, shaving, and wash- 
ing with permanganate of potash, sterile water, and oxalic acid 
solutions, then with alcohol and ether, after which the surface 
is covered with bichloride of mercury dressing (1 to 1000), thus 
completing the preparation. 

Operations upon the insane are often demanded upon very 
short notice. If the nurse is in a well-equipped modern hospital, 
she can summon plenty of help, and she is surrounded by all 
the necessary conveniences, but in private nursing her resources 
will often be severely taxed. Wherever she finds herself, she 
must remember the principles underlying all the routine pre- 
cautions, and must secure safety to the patient by painstaking 
and consistent antiseptic methods, at the same time that she 
must be resourceful in adapting many of the conveniences at 
hand to the needs of the occasion, even if she has never seen them 
so used before. The nurse's personal preparation in all emer- 
gency cases must be thorough, in that the essentials must be 
complied with, even if it must be somewhat hastily made. 

In hospital service, the various nurses who are to assist at an 
operation will be assigned their special duties — the surgically 



194 NUKSING THE INSANE [Chap. XIV 

clean ones to " run the instruments/ ' and to attend to the 
sponges and dressings; those not surgically clean to assist in 
various ways — to handle articles not aseptic, to assist the 
anesthetist, to change basins of hand solutions, to attend to the 
irrigator, and to wipe perspiration from the faces of the operator 
and his assistants with a sterile towel, taking care not to do it 
when they are bending over the field of operation, nor at critical 
times when it would interfere with important steps in the work. 
Nurses who are not surgically clean are on no account to touch 
any of the instruments or appliances that are to be handled by 
those immediately assisting at the operation; they are not to 
brush against the instrument tables, nor the gowns of the sur- 
gically clean assistants, nor to touch the arms or the hands of 
any of them; neither may they touch the towels or sheets that 
surround the wound or cover the patient or table. If it becomes 
necessary to restrain the patient when lightly anesthetized, 
nurses not surgically clean may reach under the sterile sheets 
and hold the struggling patient. It is a good rule to follow for 
every nurse who is to assist at an operation in any capacity to 
" scrub up " as though they were to be the surgically clean nurses, 
even though some of them, as they begin to assist, will be required 
to handle articles not rendered aseptic, and will thus become 
unfit for the more exacting services of the surgically clean nurse. 

Nurses need to remember that the operating room should be 
as quiet as possible; that there is to be no unnecessary talking; 
no more moving about than is really necessary, as all moving 
tends to stir up dust and so to increase the danger of infection. 
Learn the art of keeping out of the way when not needed and on 
hand when needed. 

After abdominal operations, even sane patients should not be 
left alone an instant for thirty-six hours. How much more im- 
portant is this in the insane ! The extreme thirst from which 
some patients suffer may be alleviated by means already men- 
tioned, and frequent bathing of face and hands in tepid water 
and alcohol is gratefully received in most cases. The intense 
thirst usually disappears early in the second day, likewise the 
intense pain. No movement of the trunk and no turning are 
allowed until the surgeon gives permission. When the patient 



Chap. XIV] SURGICAL NURSING OF THE INSANE 195 

is to be turned on the side, the whole trunk should be turned at 
once, to avoid twisting or pulling on the wound, the patient not 
being allowed to help herself in the least. It is a good rule in 
laparotomy cases to train the patient literally " not to lift a 
finger " for the first few days. 

In all surgical cases a cheery, healthful atmosphere should be 
maintained by the nurse, who should avoid talking about illness 
or operations. The patient's questions as to what was done at 
the operation are to be met by the nurse's invariable reply that 
the surgeon will tell her all about it when he feels that she is a 
little stronger. If questions are persisted in, the nurse should 
say that the rules of her profession prohibit her from discussing 
these topics with either her patients or their friends. 

Some of the accidents or unfortunate results to be looked for 
during or after an operation are shock, hemorrhage, hernia, and 
septic peritonitis, or infection of whatever part is the seat of 
operation. In shock the patient is dull, often in a stupor; in 
hemorrhage, he is restless and active. Pallor is common to both 
conditions, but in concealed hemorrhage the mucous membranes 
become more and more pale. Cold sweat is usually present in 
shock, absent in hemorrhage. Respiration is rapid in both con- 
ditions, but grows more and more so in hemorrhage, till the 
patient suffers from " air hunger "; likewise with the pulse, the 
rapid and weak pulse of shock improves under appropriate 
treatment, while that of concealed hemorrhage increases in 
weakness and rapidity so long as the bleeding is not arrested. 
The temperature may be subnormal in shock and is almost in- 
variably so in concealed hemorrhage. 

The treatment for shock is to remove the pillows, elevate the 
foot of the bed, wrap the patient in warm blankets and surround 
him with hot bottles, rub the extremities toward the heart, 
give a normal saline enema, and intravenous infusions if neces- 
sary, and stimulants as ordered. 

The treatment for hemorrhage is to control the hemorrhage; 
by compression and bandage, if the bleeding is in localities where 
this can be done, by a tourniquet, or direct compression with the 
fingers in places calling for these means, until the surgeon arrives. 
Stimulants, as a rule, increase hemorrhage, but may be necessary 



196 NURSING THE INSANE [Chap. XIV 

in extreme cases. If hemorrhage is in the abdominal cavity, the 
nurse must prepare for the reopening of the cavity in the inter- 
val of summoning the surgeon. Plenty of hot, normal saline 
solution should be provided, and the usual arrangements for 
abdominal operations made. When the hemorrhage is from 
the uterus or the rectum, douches and packing, and in some in- 
stances ligation, are called for. 

Minor Operations. — In minor operations on the wards, the 
things likely to be needed should be arranged on a bedside table 
and covered with a clean towel. The nurse needs to exercise 
constant care to see that mischievous or suicidal patients cannot 
get access to the instruments or disinfectants. The bed and 
clothing should be protected, the hands of the nurse carefully 
prepared and carefully cleansed after contamination before any- 
thing else is touched. 

Skin Grafting. — For skin grafting, which consists in trans- 
planting living skin from one part to some part denuded of 
skin, the following articles are likely to be needed: antiseptics, 
normal saline solution, sterilized gauze, cotton, and roller 
bandages, safety pins, razor, scalpel, tissue forceps, sharp 
curette, two artery forceps, two cambric needles, aseptic rubber 
tissue, some of which is cut in narrow strips. 

The nurse will thoroughly disinfect the skin from which the 
grafts are to be taken, the day before the operation, and on the 
removal of the sterile dressings previous to the operation, will 
rinse the surface with saline solution, and hold herself in readi- 
ness to assist as otherwise needed. The wound is washed with 
saline solution before the grafts are applied. The physician 
may require the nurse's help in spreading the grafts on the wound, 
and the strips of rubber tissue over them. A compress moistened 
in saline solution and the bandage are then to be applied. 

To prepare a Patient for Lumbar Puncture. — By lumbar 
puncture is meant the withdrawal of cerebro-spinal fluid from 
the spinal canal for the purpose of studying its composition 
chiefly as an aid to determining the diagnosis in certain mental 
and nervous disorders. It is thought to have a curative or at 
least a beneficial effect in some cases as well. This operation is 
a simple one, consisting of tapping the space between the mem- 



Chap. XIV] SURGICAL NURSING OF THE INSANE 197 

branes of the cord which contains the cerebro-spinal fluid. The 
puncture is usually made in the fourth lumbar interspace, about 
in line with the highest point of the hip bones. At this point 
there is no danger of touching the spinal cord with the needle. 

The patient's skin in the lumbar region should be surgically 
clean as well as the needle used for puncture. The patient 
may be either sitting in a chair or on a table, well toward the 
edge, and leaning well forward, or may lie on his side in bed, his 
body brought close to the edge of the bed, the head on a pillow, 
the thighs flexed on the pelvis. Ethyl chloride is sometimes used 
as a local anesthetic. The needle, a fine wire to clear the needle, 
a small rubber tube, a spirit lamp, three test tubes, a small pus 
basin, collodion and dressings, are all at hand on a tray covered 
with a sterile towel. The fluid may gush out with force, or issue 
drop by drop; it is received into three different tubes for further 
examination in the laboratory. After the withdrawal of the 
needle, collodion is applied to the punctured skin. The patient 
should rest in bed twelve to twenty-four hours after the opera- 
tion to avoid the headache and weakness that sometimes follow 
lumbar puncture. Rarely vomiting occurs after the operation. 
Normal cerebro-spinal fluid is clear. If the fluid is bloody, or 
if only clear blood escapes, the puncture will need to be re- 
peated in another place, or at a later time. 



CHAPTER XV 

CARE OF GYNECOLOGICAL AND OBSTETRICAL CASES I PUERPERAL 

INSANITY 

The duties of the nurse in gynecological cases are as follows: 
to prepare patients for examination; to assist at examinations 
and treatments; to carry out the instructions for treatment; 
to prepare patients for operations and assist at the same; and 
to give the appropriate after-care. 

By local treatment we mean the giving of vaginal douches and 
sitz baths, the use of tampons, and of topical applications. To 
the nurse is intrusted the giving of douches and baths. 

Preparation of Patient for Examination. — When a patient 
is to be examined gynecologically, the nurse's duties in preparing 
her are of a manifold nature. In the first place, the nurse must 
bear in mind that for a woman to submit to an examination of 
her pelvic organs, even by a woman physician, is an ordeal, 
and that most women, both sane and insane, shrink from it 
as we all shrink from an unknown dread. The insane, too, are 
often especially apprehensive, and the least thing out of the 
ordinary fills them with unreasoning fear. The nurse should 
remember this, and by tactful words of persuasion pave the way 
for the examination. If the case is one in which it is not yet 
known whether pelvic disorders exist or not, and the examination 
is to be done as a routine measure, just as the heart and lungs and 
other organs are examined, the nurse may say to the patient 
that the woman physician wishes her to come to the examining 
room that day that she may learn if any condition of those 
organs exists needing treatment; that if no such condition is 
found, she will not need to go again, and that if such is found, 
the doctor can probably relieve her by local treatment so that 
the general health will improve also. Some such preparation 

198 



Chap. XV] PUEEPEEAL INSANITY 199 

as this will go far to develop a right attitude toward the exami- 
nation, and should not be neglected on the part of the nurse 
as she begins her physical preparation of the patient. After 
patients have once been to the examining room, they are, as a 
rule, tractable and reasonable about the matter. Timely ex- 
planations, as suggested, will often counteract the effects of 
certain busybodies among patients who seem to delight in 
frightening newcomers with the various means of treatment in 
store for them. 

The body of the patient should be scrupulously clean, especial 
attention being given to the vulva and anus; the underwear 
should be clean also, and the rectum and bladder empty. It is 
well to give an enema, even if the bowels are not considered 
constipated, as insane patients are so unreliable in this respect, 
and it is exceedingly annoying to the physician to have a patient 
put upon the table only to find that the rectum is so full that 
a satisfactory examination cannot be made. If the patient 
objects to the enema on the ground of its being unnecessary, 
explain to her that there may be an accumulation higher up, 
and that you wish to make sure that the passages are thoroughly 
evacuated. Have the patient urinate shortly before going to 
the examining room. A vaginal douche should not be given, 
as a rule, before the first examination, as the physician usually 
prefers to see the exact character and amount of the uterine 
and vaginal secretions. After the initial examination, vaginal 
douches are usually in order, the quantity, character, and tem- 
perature being modified to suit individual cases. 

Nurses who accompany patients to the examining room should 
be prepared with pad and pencil to take down instructions 
regarding the time of removal of tampons in each case, the tem- 
perature of douches, and other special instructions. 

The charge nurse should send with her patients a nurse who is 
conversant with certain important facts in the case — the full 
name of the patient, her general behavior, her special physical 
complaints, such as leucorrhea, backache, headache, and the 
like, her habits as to masturbation, if such exist, the facts con- 
cerning her menstruation, the time of the last period, the regu- 
larity and quantity of the flow, and whether or not pain or other 



200 NURSING THE INSANE [Chap. XV 

conspicuous symptoms are present during the menses. It is 
inexcusable for a charge nurse to send a patient to the examining 
room with an attendant so ignorant of the case that this infor- 
mation, if necessary, cannot be elicited from her. 

Each patient should be provided with a toilet napkin and 
safety pins and, if medicated tampons are inserted, these napkins 
should be applied immediately after the patient descends from the 
examining table, in order to protect the clothing from being wet 
and stained by the applications made. Dull or feeble patients 
require the nurse's assistance in properly adjusting napkins. 
Where glycerine or boro-glyceride are used, the napkins in some 
cases require frequent changing, as the use of these substances 
is followed by excessive secretion from the parts, and unless 
precautions are taken, unsightly and unnecessary staining of the 
clothing takes place when certain other medicines are incor- 
porated in the mixtures. 

In taking several patients to the examining room, especial 
supervision needs to be exercised that suicidal or mischievous 
ones do not slip into the operating room, or the rooms where 
supplies are kept (in case such rooms are in close proximity), 
and so perhaps obtain means for injuring themselves or others. 
And when in the examining room, the nurse must be on her guard 
to see that patients do not gain access to the bottles of medicine, 
or disinfectants, or the instruments, and that violent or meddle- 
some ones do not interfere with the examining table or other 
objects in the room. Some angry and belligerent patients will, 
unless prevented, sweep a whole row of bottles from the table, 
seize and break the foot rests, grab at the instruments, or attempt 
to do violence to the physician, especially when the head is in 
close proximity to the patient's heels while treatment is in 
progress. 

In hospital work the nurse should see that the patient re- 
moves her corset, if one is worn, before going to the examining 
room, and wears open drawers. All tight waistbands should 
be loosened before the patient is assisted to mount the table. 
The use of the sheet to cover the patient should never be omit- 
ted, whatever the position used, even if the patient herself seems 
lost to all sense of modesty. This sheet should be scrupulously 



Chap. XV] PUERPERAL INSANITY 201 

clean; it is variously draped, according to the positions em- 
ployed. Any method of drapery easily and quickly applied, 
and which affords protection from unnecessary exposure, and 
does not interfere with the physician's work, will usually be 
acceptable. Some patients are so violent and resistive that all 
efforts to protect them from exposure are almost fruitless; in 
such cases the nurses have to help maintain the necessary posi- 
tion, as well as to guard against violence. 

Pains should be taken to keep the instruments out of the 
patient's sight, and all other things as well that would cause 
apprehension, or be offensive in any way. Care should be taken 
to avoid unnecessary noise in handling the instruments; some 
nervous patients almost get into a panic at the sight of the long 
dressing forceps with a piece of cotton attached. The soiled 
towels should be gathered into the hamper before the patient 
is allowed to rise from the table. The trays containing the bits 
of cotton used during the treatment, as well as those holding 
the instruments, should be covered, or, if on swing doors on the 
table, closed in out of sight before the patient descends from the 
table, and pulled out into place for the convenience of the phy- 
sician after the next patient is arranged on the table. 

Due care should be taken in assisting a patient on and off 
the table not to let her slip, nor get her clothing caught in the 
foot rests, nor to let the clothing or the cover sheet get wet at 
any time by falling into the trays containing the antiseptic solu- 
tions for the instruments. 

When patients are put in the recumbent position, the nurse 
should herself raise the patient's feet to the stirrups, and in 
helping her to dismount, the patient should be told to turn on 
the side before rising from the table, so as to avoid unnecessary 
strain. 

The nurse will learn from practical demonstrations how to 
prepare the patient for the various positions used in examina- 
tions and operations. The erect position, the dorsal recumbent, 
the lithotomy position, Sim's position, and the knee-chest 
position are the ones most likely to be used. 

Since the dorsal recumbent position is the one most frequently 
used, we shall consider it in some detail. The patient is told to 



202 NURSING THE INSANE [Chap. XV 

face the nurse who stands at the foot of the table and to step 
upon a low stool at the foot. The nurse holds a half-open sheet 
before the patient at a level with the hips, the patient being 
instructed to lift her skirts behind and to seat herself close to 
the lower end of the table. The sheet is then laid over the pa- 
tient's lap and she is assisted to lie down; the nurse places a 
small pillow under the head, adjusts the feet in the stirrups, 
and separates the knees as far as possible. Until patients be- 
come accustomed to taking the position, they will always sit 
too far back from the end of the table; most of them will have 
to be told to lift the hips and let you draw them down so that the 
buttocks slightly project over the table's edge, as this is the 
position best suited to the convenience of the physician. The 
lower part of the sheet is then folded under the edge of the skirts, 
and after being pushed upward some distance, skirts and sheet 
are folded inward toward the abdomen. A folded towel is 
placed under the buttocks to protect the clothing and table 
from the medicines used. At any time when patients are on 
the table, if there are pauses or interruptions in the work, the 
drapery should be dropped temporarily so as to conceal the 
genitals from view. 

The duties of nurses in assisting the physician at gynecological 
examinations vary according to the number of nurses provided, 
the customs of the physician, the character of the patients and 
their condition, and also according to the degree to which anti- 
septic technique is enforced. In New York State hospitals, 
where there are classes in training, the clinics are usually so 
arranged that the pupil nurses take their turn in the various 
offices required of them — in assisting the patients on and off 
the table ; in learning to pose and drape them in the different 
positions; in preparing and handing the instruments and in 
washing and disinfecting them; in washing the genitals with 
an antiseptic solution just previous to the ocular and digital 
examination; in lubricating the speculum and in medicating 
the tampons; and in rendering whatever other assistance may 
be required. Where there are several nurses to assist, one nurse, 
as well as the physician, keeps surgically clean, the other assist- 
ants handling articles not aseptic. This surgically clean nurse 



Chap. XV] PUERPERAL INSANITY 203 

should observe as strict technique as though she were assisting 
at surgical operations; the training thus pursued is excellent 
preparation for the gynecological operations at which she will 
assist later. 

The nurse can help much during the digital examination by 
keeping the patient's knees separated, the clothing and drapery 
from getting disarranged and in the physician's way, and by 
encouraging the patient to breathe deeply, preferably with the 
mouth open, and so relax the tension of the abdominal muscles. 

The physician will indicate the kind and size of speculum to 
be used. The nurse, if surgically clean, lifts the speculum from 
the tray, lubricates the outside of the blades, and hands it to 
the physician in the direction in which it is to be used. Or if 
she is nurse-of-all-work, so to speak, the tray is arranged in 
reach of the physician, who lifts the speculum himself and applies 
the lubricant to it. If lysol is used in the instrument trays, 
a lubricant is unnecessary. A speculum should be neither too hot 
nor too cold nor too much anointed. Uterine forceps with bits 
of cotton are then needed to clear away secretions that may be 
seen on the vaginal or cervical mucous membranes. Other as- 
sistance will depend upon the nature of each case. 

If the physician calls the attention of the nurse to any con- 
dition about the patient, or tells her to look in the speculum, 
or if in any way the nurse obtains information about conditions, 
she must be on her guard to avoid expressing surprise or con- 
sternation at what she learns, either by voice or facial expression, 
as nervous patients are easily made more nervous by chance 
remarks of nurses and physicians. An " Oh, my ! " or a look 
of pity or of surprise at perhaps merely a cervical erosion which 
an inexperienced nurse sees for the first time, may make the 
patient think that she has some serious thing the matter with 
those parts, and that the physician is keeping her in the dark 
about it. 

In gynecology, douches are given for cleansing purposes, to 
relieve inflammation, to check hemorrhage and secretions, and 
for purposes of stimulation. They should be given carefully, 
with conscientious regard to quantity, temperature, and other 
specifications. 



204 NURSING THE INSANE [Chap. XV 

Especial care is necessary in the giving of douches and enemata 
after perineal operations not to press the nozzle of the syringe 
against the repaired tissue, but against the opposite wall. Sterile 
douches may be ordered every twelve hours after perineal cases, 
and twice a day after cervix operations. It is important that 
the vagina should be dried after douching in perineal cases, by 
using cotton on forceps, so as not to soften the stitches. Vaginal 
or uterine packings of sterilized or medicated gauze are usually 
left in for twenty-four or thirty-six hours after operations, re- 
moved with sterile forceps, and followed by a sterile douche, 
if ordered. When packings are placed, the temperature is usually 
taken every two hours, and if it reaches 101° F., the packing 
is removed. 

In cases where a catheter is left in the urethra for some days 
after operations, it is to be removed and cleansed every few 
hours; a second aseptic catheter should be at hand to replace 
the one removed. 

The Care of the Pregnant Woman. — After the seventh month, 
the urine should be frequently examined. Swelling about the 
eyes should make one suspicious of the presence of albumen. 
In such cases the diet needs to be restricted to milk chiefly, 
and the quantity of urine carefully watched, as convulsions at 
the time of confinement are to be feared. Saline enemata, 
warm baths, copious drinking of water are remedial measures 
in this condition. 

The nipples should receive preparatory treatment. If the 
breasts are so heavy as to need support, they may be comfortably 
bandaged, leaving the nipples uncovered. The nipples should 
be washed daily with warm water and soap and anointed with 
a little cold cream. If they are inclined to be flat or retracted, 
an attempt to develop them should be made by drawing them 
out with the thumb and finger, or a breast pump may be used 
toward the later months of pregnancy. Some physicians order 
daily nipple baths of alcohol and water to prepare the nipples. 

Threatened Abortion or Miscarriage. — If at any time during 
pregnancy the woman has even a slight flow of blood from the 
vagina, she should go to bed and keep as quiet as possible, and 
send for her physician if it continues. If the bleeding is at all 



Chap. XV] PUERPERAL INSANITY 205 

conspicuous, the head should be lowered, the hips elevated, the 
foot of the bed raised, hot drinks avoided, and perfect quiet 
maintained. If the flow becomes alarming, a hot sterile douche 
(110° to 115° F.) may be given. The strictest antiseptic measures 
are necessary in these cases. All blood and blood-stained sheets 
or cloths should be saved for the inspection of the physician. 

Management of Pregnancy. — It happens on rare occasions 
that the nurse finds herself in a position where she has to con- 
duct the labor alone, the labor being so precipitate that the 
physician cannot be summoned in time. If confronted by this 
emergency, go about it calmly, not letting the patient know 
that you are not accustomed to render such service. The 
patient should lie upon her left side at the edge of the bed, 
the thighs being drawn up and a pillow placed between the 
knees. Thoroughly cleanse and disinfect your hands, and have 
a basin of bichloride of mercury (1 to 2000) and gauze or linen 
sponges within reach. Place a gauze sponge over the anus. As 
the head comes down, your hand should gently support the 
perineum; encourage the patient to cry out, or to open the 
mouth widely as the head presses the perineum. Receive the 
head in one hand, supporting it so that its weight does not 
drag upon the parts; with the other hand wipe out the eyes 
and mouth, and patiently wait, without pulling, until another 
pain comes and expels the child, which you will receive in 
the unoccupied hand. As soon as the head is born, pass your 
index finger to the neck to feel if the cord is around the neck; 
if so, pull it out and slip it over the head. When the body is 
expelled, turn the child on its right side, taking care to put its 
face out of the way of the discharges from the mother, lay a 
blanket over it, and leave it there for a little while, turning your 
attention to the uterus to aid its contractions. Grasp this organ 
through the abdominal walls, and rub gently or squeeze it for 
a little while to make sure of its contracting. When the cord 
has ceased to beat, tie it with two pieces of aseptic bobbin, then 
cut the cord with surgically clean, dull, and preferably blunt- 
pointed scissors, taking care not to injure the baby if it is kicking 
about during the procedure. 

If the child fails to cry, strike the buttocks or the bottoms of 



206 NURSING THE INSANE [Chap. XV 

the feet vigorously, or dash cold water on the chest, or rub alcohol 
or vinegar on the pit of the stomach, or moisten the lips with the 
finger dipped in alcohol. If these methods fail, artificial res- 
piration will need to be used. After breathing is established, it 
is well to place the child in a warm bath and use gentle friction 
till the skin becomes reddened. Then wrap the child in a warm 
blanket and put it on its right side in a warm, safe place until 
you have leisure to attend to it further. 

Soon after the child is expelled, turn the patient upon her 
back and grasp the uterus as before stated. 

When the placenta is seen at the outlet, grasp it and draw 
it gently downward and backward in a rotary way so that the 
membranes will twist on themselves as they come away; do not 
pull on the cord or the placenta, nor put your fingers in the 
vagina. The placenta is to be saved for the inspection of the 
physician, also all clots and discharges. After the placenta has 
come away, the uterus usually contracts still farther, there is 
but little oozing of blood, and the patient can soon be bathed 
and made comfortable by clean dressings and a binder, and 
allowed to sleep. The pulse usually drops after labor to about 
80 or less; if it continues at or above 100, hemorrhage is to be 
feared. 

Convulsions occurring during labor usually call for the speedy 
termination of labor. Chloroform is given during the convul- 
sions, and if labor is not advancing rapidly enough, the child 
is delivered either by turning or by instrumental delivery. The 
nurse should try to prevent the patient from biting her tongue 
during convulsions. The administration of chloroform for 
partial anesthesia is, in these cases, usually intrusted to the 
nurse. A few drops are put on a folded handkerchief, and the 
latter held over the nose only during a pain, or a convulsion, as 
the physician directs. 

The main thing in nursing during the puerperal period is to 
keep the patient clean, quiet, well nourished, comfortable, 
and cheerful; to give the baby regular and sufficient care, and 
to let it sleep as much as it will when not being bathed, fed, or 
otherwise attended to. 

The patient's temperature, pulse, and respiration should be 



Chap. XV] PUERPERAL INSANITY 207 

taken and recorded morning and evening for two weeks, or 
longer if it does not run a normal course. The amount of nourish- 
ment, the condition of the bowels, bladder, breasts, and the 
lochial discharge, are matters concerning which full reports 
should be made to the physician. The nipples should be bathed 
after each nursing with a boric acid solution, and the child's 
mouth washed before and after each nursing. 

Morbid Excitement or Depression during Pregnancy. — (Puer- 
peral Mania or Melancholia.) One or the other of these con- 
ditions may come on during pregnancy, or immediately after 
confinement, or later, during lactation, when the woman is 
exhausted with nursing the baby, with worry, or with physical 
ill health. 

Alterations of character, not amounting to insanity, may 
occur during pregnancy; for example, fretfulness, forebodings, 
capricious conduct, craving for unnatural and even disgusting 
things, and these may be accompanied by jealousy and suspicion 
of the husband, or of those who have the immediate care of the 
patient. These unusual symptoms may go no farther in some 
cases, but in others may be the forerunners of graver morbid 
manifestations that show themselves just before or shortly after 
confinement. 

Perhaps a few days after confinement the nurse will notice 
that the patient is unusually talkative, restless, capricious; 
she sleeps but little, her appetite is poor, and she seems indif- 
ferent to, or even actually shows dislike to, the baby. These 
symptoms call for the closest vigilance and the most careful 
nursing. They are most often found in company with infection 
symptoms, especially in patients with a nervous or insane hered- 
ity. They are likely to go on to more and more pronounced 
symptoms of either excitement or depression, and the nursing 
has to be directed toward counteracting the exhaustion that is 
likely to follow. 

As the child is usually taken from the mother and fed arti- 
ficially, the breasts require the usual care of emptying and 
bandaging to cut off the supply of milk. 

Whether the condition is one of exaltation or depression, the 
child's life is usually unsafe when near the mother, and its pres- 



208 NURSING THE INSANE [Chap. XV 

ence, as a rule, only serves to aggravate her condition. Some 
insane patients attempt to destroy the child while it is being 
born; a case in mind tried to choke the child between her own 
thighs. Some patients give no sign that the labor is in progress 
till it is well on toward completion. In one instance I have in 
mind, the first intimation the nurse had that the patient was 
in labor, she heard the child cry, and searching for it, found it 
lying in the bowl of the water closet. 

Patients in these unnatural mental states accompanying preg- 
nancy, or the puerperal period, are often suicidal and very shrewd 
and sly. 

The patient must not be left alone an instant day or night. 
She may feign sleep in order to get the nurse off her guard. 
The windows must be guarded, doors locked, all medicines, 
instruments, and disinfectants kept under lock and key, and 
everything removed from the room with which the patient could 
in any way injure herself or others. 

Abundant nourishment and antiseptic nursing are the most 
important features of the treatment. Forced feeding may have 
to be resorted to. 

Your experience with the insane in general makes it unneces- 
sary to dwell longer on these conditions, since to obstetrical 
nursing you have but to add the care you would give to uncom- 
plicated cases of excitement or depression, as the case may be. 



CHAPTER XVI 

OCCUPATION AND AMUSEMENT OF PATIENTS 

It is an uncomfortable reflection, but one that often forces 
itself upon me, that many patients now considered hopelessly de- 
teriorated, could have been saved from drifting into the depths 
of dementia in which we see them, had their hands been kept 
occupied, their muscles trained to regular tasks, and their 
intellects stimulated by interest in some wholesome work. 

It should be remembered that idleness of the mind is as great 
an evil as that of the body. There are patients that are kept 
at a daily round of tasks as in a treadmill — tasks to which no 
interest, no joy in the work, and no intelligence, is brought — 
just automatic accomplishment of certain routine things they 
have been trained to do. But even that is better than sloth, 
and that is perhaps all that certain ones are now fitted for. It 
is not intended to belittle such work if patients are incapable 
of more intelligent occupation. We need to remember that even 
this automatic employment is useful, in that it keeps their bodies 
exercised, it expends muscular energy that would probably 
otherwise find its outlet in noise, mischief, violence, or destruc- 
tiveness ; it lessens the great army of the unemployed, thereby 
reducing the disheartening effect on every one who witnesses the 
large body of idlers; and lastly, its economic value, in the actual 
work accomplished, is of importance, although we need always 
to bear in mind that this is the least important reason we have 
for urging the occupation of patients. They are to be urged to 
work when and only when work is good for them, and not because 
the work is there to be done. Willing workers must not be 
overtaxed, and intemperate workers must not be allowed to go 
to the excess that some of them are prone to unless safeguarded. 
Supervision to prevent overwork is as important, though less 
frequently needed, as is stimulation of the slothful, 
p 209 



210 NUKSING THE INSANE [Chap. XVI 

Occupation is an important part of the treatment of the insane, 
and should receive more systematic attention than it does at 
present. Each patient should be studied in this respect, his 
strength, his age, his previous condition and station in life, his 
tastes and capabilities — all these considerations entering into 
the choice of the work assigned him. If due attention be given 
to these things, with the exception of the physically weak and 
depressed, the acutely maniacal, and the infirm, there is scarcely 
a patient but will be materially benefited by regular, systematic, 
and judiciously prescribed employment. 

There is no remedy for the evils arising from sensuality equal 
to that which cultivates an intellectual interest in things. Patients 
who have become self-indulgent to the point of sensuality usually 
get dull and inactive; and gluttony, masturbation, and other per- 
versions follow. Bodily exercise for such cases is excellent so 
far as it goes, but it needs to be supplemented by things that will 
stimulate the mind if we hope to prevent or to eradicate these 
vicious propensities. 

A congenial occupation demanding one's attention furnishes 
a healthy channel for the thoughts, and thus morbid fancies 
get crowded out. Even in the physically weak and infirm, 
where the bodies must remain inactive, it is well to furnish 
some light occupation for the mind, suited, of course, to each 
case. A few minutes' reading to such patients, some bright 
anecdote or short story, some description of travel that will give 
them food for healthful thought throughout the day, some in- 
teresting details in the lives of men and women engaged in the 
world's work — accounts of human achievement; selections 
along such lines, made by a thoughtful nurse, and either read 
by her, or by some one whom she designates, will do much to 
entertain, and perhaps to restore to mental health. For it is 
the getting away from self, the keeping of the mind interested 
in the big world of which we are a part, and the keeping alive 
the feeling of brotherhood, that helps us all to maintain healthy 
interests; and if these are dormant, such means will help to 
awaken them, and so crowd out morbid fancies, and leave little 
time for harmful propensities. 

Patients who have poor eyesight, or those who, for any reason, 



Chap. XVI] AMUSEMENT OF PATIENTS 211 

cannot read, should receive special attention in the matter of 
being read to and entertained, and of having letters written for 
them. Nurses can often enlist other patients in this service, and 
so kill two birds with one stone; the one who reads is benefited 
as well as the one read to, perhaps more so. 

There should be variety in occupation; monotony is wearisome 
and deadening, while variety is assuredly the spice of life. Avoid 
getting in ruts yourself, or letting your patients do the same. 
Unless watched, some patients will show undue zeal in Bible 
reading, in piano practicing, in card playing, in embroidery, or 
in whatever pursuit they develop an interest. Tact in breaking 
in upon their monotonous occupations needs to be exercised. 
But unless monotonous ones are broken up, they cease to be help- 
ful, for when so nearly automatic as some of them come to be, 
they lose their beneficial effect upon the mind. 

Nurses need to remember that new patients must not be set 
to work until their occupation in kind and degree is sanctioned 
by the physician. But do not let the physician lose sight of this. 
Call his attention to the unemployed, and secure his help in ini- 
tiating occupation, should he fail to attend to the matter after 
sufficient time has elapsed to observe the patient. 

In all occupations, nurses and attendants need to keep con- 
stantly in mind that their patients and their work must be 
supervised conscientiously in order that no tools or objects that 
could be used as weapons shall be allowed in the hands of 
patients who cannot be trusted with them. 

Attendants, when supervising work of patients, should become 
party to that work. It is inexcusable for them to sit idly by, 
or to walk or stand about, giving their orders merely, while 
enjoining industry on the part of others. Where the work is 
such that a general supervision must be kept up, the attendant 
cannot always work steadily, but the really efficient one will 
find means for lending a hand here and there and making the 
patient feel that he is practicing industry as well as preaching it. 

A cheerful attitude toward work is contagious, and all who 
have the direction of patients in this particular can do much to 
make of occupation a pleasure. Begin the day's work with a 
cheery manner, let jest, banter, and even good-humored raillery 



212 NURSING THE INSANE [Chap. XVI 

abound, encourage patients to talk, to sing, to whistle, and to 
have a good time while working. In so doing, you will guard 
against the feeling that work is irksome. 

I hope the time will come when, in addition to the various 
industrial shops in vogue in some hospitals, there will be regular 
schools where the truths in kindergarten methods will be made 
applicable to patients; courses of instruction adapted to the 
needs of various classes and conditions will help in upbuilding 
mental health; workshops where various handicrafts will be 
taught, and gymnasia where body building will be regularly 
and systematically attended to. 

I wish to emphasize the necessity for individualization in the 
choice of occupation, the particular work being suited to a given 
patient, and to the patient's existing condition. Never allow 
him to jog along day after day in work which, though it may 
have been suited to him at one time, is now, by reason of advanc- 
ing age, or poor health, or for any reason, no longer adapted 
to his strength. 

Patients should, in general, be encouraged first to do all they 
can to help themselves, and then to do something each day to 
help others. To begin with, they should be trained to look after 
their own persons, their bathing, care of the hair, attention to 
nails and teeth, to their bodily functions, and to dressing them- 
selves and keeping their clothes brushed and mended and neatly 
arranged. They should air and make their beds, keep their 
rooms tidy, and be encouraged to do things to add to the at- 
tractiveness of their rooms. Women patients can, by various 
little touches, give a homelike air to their surroundings, and 
many men show a like aptitude. Still others undoubtedly would 
if they were encouraged to do so. Stand and bureau covers, 
picture frames, book shelves, pillow shams, baskets, slumber 
robes, artificial flowers, braided mats and rugs — these are a 
few of the things that come to mind that patients can make or 
arrange to add to the attractiveness of their rooms. It is often 
surprising what ingenuity and resourcefulness some of them 
evince in these directions, often making unique and artistic 
things from very simple and unpromising materials. 

Basket weaving offers a most absorbing occupation for many 



Chap. XVI] AMUSEMENT OF PATIENTS 213 

women, and the nurse can often do much to interest friends of 
patients to supply them with materials for such work. 

Some patients can be interested in saving magazine pictures, 
and with a passe-partout outfit add to the attractiveness of 
their rooms. Others make scrapbooks and picture books that 
are a source of real interest to themselves and others. These are 
especially acceptable in the hospital departments. 

Interesting picture frames can be made of acorns and acorn 
cups, beechnuts, birch and other barks. Attractive and inex- 
pensive splashers and bureau covers can be made from silkaline, 
dotted muslins, scrim, burlap, denim, and the like, the patient 
often following out a certain color scheme that gives the room 
a harmonious and individual atmosphere. 

In these days so much can be done with carpet rags that it 
seems a pity not to keep patients at sewing rags, even if they 
won't do anything else. Men patients find welcome outlet for 
their energies and capabilities in work on the farm and in the 
garden, in the various shops, the laundry, and other like places. 
The women can also be employed in the laundry, the kitchen, the 
sewing rooms, and on the wards, and they are always the happier 
for occupation which makes them feel of use, and in which they 
can be trained to take a personal interest, although at the start 
many of them have to be roused from the inertia into which they 
have fallen. This rousing is where the intelligence and patience 
of the nurse come into play. Patients incapable of any other 
occupation can be trained to pick hair for renovating mattresses. 

You can often give a festive air to what might otherwise be a 
dull, uninteresting task. Suppose a certain lot of needlework 
has to be done in a given time. Invite your patients to a sewing 
bee or a thimble party at a certain day and hour, the affair to be 
heralded, perhaps, by a humorous placard posted in the hall; 
carry the thing through with fun and nonsense; serve a cup of 
tea or cocoa in the afternoon, and while the time away, besides 
sewing, in various ways which your own ingenuity will suggest 
if you really set about it. 

A lot of fun can be got out of simple things, and a good laugh 
and pleasant recollections called up by the veriest nonsense. 
For example, with a party of assembled patients sewing and 



214 NURSING THE INSANE [Chap. XVI 

chatting, you can, by way of diversion, start them to recalling and 
reciting, in turn, nursery rhymes, or Mother Goose melodies, 
perhaps making them pay forfeits for failure to respond or to 
quote correctly. 

Another time have autograph album verses, or bits of poetry 
quoted, or cast lots and have one tell a story, or have some one 
tell what she can remember of the best book she ever read, or 
have them mention their favorite old songs, each one seeing who 
can recall the largest number. All this can be done without in- 
terrupting their sewing, as any one who has attended thimble 
parties knows that tongues and needles can fly simultaneously. 
These few suggestions will not be applicable to all patients, nor 
at all times, and their employment will require tact on the part 
of the nurse, but they, and many others that will suggest them- 
selves to you, will be applicable at times, and will, I believe, if 
put in practice, contribute largely to the pleasure and jollity, 
the home atmosphere, the harmonious working together, and so 
to the well-being of your patients, and oftentimes, even to their 
restoration to mental health. 

Sunday nights on the wards should be especially marked by a 
little cheerful social intercourse, the singing of favorite hymns, 
perhaps a Bible reading, or Bible quotations, Bible charades, a 
Sunday-school class, and the like. I have known of most in- 
teresting Bible classes conducted by a patient or patients for 
months at a time, and made a source of much comfort and 
interest to a large number. 

If you have a German or a French patient on your hall who 
can be enlisted, you can often start a class in the study of these 
languages, not necessarily in a formal or very ambitious or very 
thorough way, but very simply and in a way adapted to the needs 
of the ones to be taught and of the ones who teach — perhaps 
just teaching them the names, for example, in German, of the 
common articles about them, parts of the body, furniture, food, 
and table utensils, the alphabet, how to count, the months and 
days, and such simple things. Then encourage them to put 
their acquired knowledge in practice at the table and on the 
wards. This will not only interest and stimulate their minds, 
but will add to the feeling of fellowship between them; it will 



Chap. XVI] AMUSEMENT OF PATIENTS 215 

make the foreigner one with them, and will make them feel that 
they are acquiring something outside the daily round of things. 

Chess, checkers, dominoes, billiards and pool, cards of various 
kinds, word games, puzzle maps, Halma — these and others all 
have their places, and should be intelligently enlisted in the 
amusement of the patients. Baseball, basket ball, croquet, 
and tennis are games easily pressed into service. 

I have unconsciously drifted into the subject of amusement 
when writing of the occupation of patients, but that is as it 
should be — work and play blended, and plenty of play mingled 
with the work. All work and no play makes Jack a dull boy, 
and it is particularly bad for Jill, too. Many of the Jills under 
our care come here because their lives have been one dull round 
of work, with no time for the brightening and wholesome influ- 
ences of play. 

It is a lamentable truth that not a few of our patients have 
always led such treadmill lives that their first experience with 
fun and a good time has come to them within the walls of a 
hospital for the insane. Some of these, on the eve of going home, 
have even been known to sigh and say, " I shall miss the dances 
and the other good times I have had here " ; and these not, as 
one might imagine, the young and giddy, but staid middle-aged 
matrons who have here seemingly learned for the first time in 
years what it is to relax and really have a little fun. 

Some of your patients have never learned to read. Not that 
they do not know how to read, though, of course, this is true of a 
number of them, but I mean that they have never acquired the 
habit of reading, some from lack of time, others from lack of 
inclination. Here is your chance, at least with those who have 
heretofore had but little time for reading, to encourage them to 
acquire a love for reading. The habit of reading is a very present 
help in trouble. Be careful how you belittle the days when it is 
your ward's turn to send patients to the library. Reflect what 
power there is in a book, and be active in stirring your patients 
to a lively interest in the selection of reading for themselves and 
for other patients who are unable to leave the ward. 

I have known a chance sentence read from a book to be the 
carrier of hope to one in the Slough of Despond ; I have known the 



216 NURSING THE INSANE [Chap. XVI 

sight of a beautiful picture to be a heaven-sent message to a 
beclouded mind ; and the hearing of good music, sympathetically 
played, to be the key that unlocked an imprisoned soul, letting 
it out into sunlight and peace once more. Then let us be awake 
to all the influences that can be brought to bear on the sick bodies 
and minds intrusted to us, remembering that the mildest power 
is often the greatest, and that a seemingly little thing may have 
an incalculable effect on that complex thing, the human mind. 

On days when the weather admits of it, see to it that every 
patient who is able goes out of doors. Do not allow the sedentary 
and the apathetic to mope day after day indoors when the health- 
bringers, fresh air, sunlight, and exercise, are so close at hand. 

It may require considerable tactful effort on your part to 
establish the habit of going out in certain ones averse to it; 
but when it is established, it will help to sweep the cobwebs from 
their brains. And when you are out with patients, seek to make 
their daily walks a source of interest and benefit to them. You 
know that the rules require, in substance, that you are to see that 
each patient going out for exercise is neatly and suitably clad, 
according to the season, and that you know how many and who 
are under your care ; that you are expected to exercise especial 
supervision of the untrusty and the vicious ; that stragglers are 
not to be permitted to stray too far behind ; that feeble ones are 
not to be taxed beyond their strength; that unseemly conduct is 
to be prevented so far as possible ; and that your charges are to be 
safely returned to the wards, being counted in as carefully as 
they are counted out. 

Is your whole duty done when these things have been accom- 
plished? I admit that to do these things enumerated, with a 
certain class of patients, requires about all that the nurses and 
attendants can compass; but there are times and seasons, and 
with certain classes of patients, when much more can be done, 
and the nurse who will cultivate in herself a love for out-of-door 
life will find ways and means for communicating her love and 
interest in these things to her patients. One need not necessarily 
take up a serious course of nature study, though a more whole- 
some and rejuvenating pursuit can hardly be found; but can 
simply begin by learning to see with a fresh eye and feel keenly 



Chap. XVI] AMUSEMENT OF PATIENTS 217 

the common beauties of the sky, the grass, the trees, the distant 
hills, the wayside flowers, the ever-changing light and shade on 
the face of Nature, and the infinite variety unfolded from hour to 
hour, and day to day, throughout the varying year. 

Be on the alert for fresh arrivals in the birds, catch their 
first calls in the spring, attend to the brown earth as it begins to 
be pierced with all manner of green things that unfold from day 
to day, let your glances flit about with the butterflies that hover 
near, learn to be stirred by the promise of awakening spring, 
exult in the radiance and beauty of summer, bask in the mellow 
fulfillment of autumn, and respond with briskness and vigor 
to the challenging forces of winter, and so become at one with 
Nature in all her changing aspects. When you are yourselves 
alive to these things, you cannot help making your patients 
keenly aware of them also, and you will put your wits to work to 
see what each walk can bring of pleasure and stimulation to your 
patients. 

Begin by teaching them to observe. It is surprising how few 
people really use their native powers of observation, how few, 
though having eyes and ears, really see and hear. 

A spring walk can be made very full of interest by asking each 
one to see how many signs of early spring each can discover, by 
sight or sound, or whatever sense it may be. Watch for the music 
of the swollen brook, the first bluebird's note, the yellowing of 
the willows, the appearance of skunk's cabbage, the blossoming 
of the hepatica, the swelling of the tree buds, and the unfolding 
of the various flowers in their turn as the season advances. 
When they become abundant, appeal to the love of collecting, 
so common to many people, and interest them in seeing, for 
example, who can gather the greatest variety of leaves in a given 
walk, or the largest number of flowers, or who can note the 
greatest variety of birds, and identify their songs, and perhaps 
find their nesting sites. When these are found, the amount of 
interest in the building of the nests and in the rearing of the 
broods is a most absorbing source of delight. Right on our 
lawns are exceptional opportunities for these observations, and 
in the woods, in the rear of the buildings, through which your 
daily walks take you, are more varieties of flowers than are 



218 NUKSING THE INSANE [Chap. XVI 

dreamed of in your indifference, unless you have really attended 
to these things. 

The various leaves and flowers gathered can be later identified 
and studied with the help of books from the library, and the 
help of others who are farther on in the study of these things 
than you are. Attempts at drawing the leaves can be made, 
and furnish much amusement, and often lead to an interest 
deeper than mere amusement, for dormant capabilities may be 
discovered in persons ignorant of any ability in this direction. 

Let me mention a few books that may help you in these 
studies: Parkhurst's " Bird Calendar," Mrs. Dana's " How to 
Know the Wild Flowers " and "According to Season," Francis 
Theodora Parsons's " How to Know the Ferns," Marshall's 
" Mushroom Book," Gibson's " Sharp Eyes," Neltje Blanchan's 
" Nature's Garden," Dugmore's " Bird Homes," and Keeler's 
" Our Native Trees." Then there are the delightful essays of 
outdoor life to be found in the works of John Burroughs, which 
are in themselves invigorating and inspiring as is Nature herself, 
as well as many other books on kindred topics which are to be 
had by applying for them at the library. 

There are other expedients to be tried, too. A lot of fun can be 
had in early spring by making up a party and going for " greens," 
going to some moist meadow for cowslips, to the fields for nar- 
row dock or milkweed, on the lawns for dandelions, and to the 
brooks for water cress. The delight of these excursions, the 
infrequency of them, and the toothsome flavor that the gathered 
products yield in the dinner later, are all beneficial to a marked 
degree. Another spring pursuit, that ought to appeal to the 
poetic sensibility of the most prosaic, is the spring pastime of 
gathering dandelions for wine. 

It is a good plan on all the wards, but especially on those where 
tubercular patients are located, to make frequent occasions for 
practicing lung gymnastics. This can be done on the balconies 
and in the sun rooms, and it is particularly desirable that it be 
done frequently when out for walks. Suggest to your charges, 
" Let us see who can expand the chest the best." Then instruct 
them how to begin, by inhaling a deep breath through the nose 
and take, say, three steps while holding it, then slowly let it 



Chap. XVI] AMUSEMENT OF PATIENTS 219 

out, through the nose also; next time hold it for five steps, then 
for eight, then ten, and so on, till each one in her effort to excel 
finds herself filling her lungs with pure air, as they are seldom 
filled, thereby increasing her sense of well-being and her actual 
good health, while she is only conscious of having some pleasur- 
able change in a customary exercise, a change that has added 
zest to it by means of this simple expedient. 

Did you ever hear of a " Giggle class " ? Even this, as silly 
as it seems, may be made beneficial, and it certainly is amusing. 
Ten persons are asked to stand in a circle. Beginning at one 
point, one says " Ha ! " the next follows, and so on around. 
The next time around, " Ha, Ha ! " more rapidly, and again 
more Ha's and still more rapidly, until all lose their turn in their 
effort to catch it up, and so, what started out to be a mechanical 
giggle, becomes a downright laugh in good earnest in all round. 

Some of these suggestions may seem very trivial, but at the 
risk of their appearing so, I mention them with the hope that, 
even if the ones suggested are not tried, they will at least put you 
in mind of others that may appeal to you as better and more 
suited to the particular cases with which you have to deal. 

Sometimes exercise is not the thing to be recommended; in 
certain cases just the opposite is to be enjoined. With some 
agitated and restless patients your help is needed to quiet mus- 
cular activity, and here you are often confronted by a difficult 
task. Sometimes you can gain a patient's attention and induce 
her to sit perfectly still for at first one half minute, three quarters, 
one minute, and so on, gradually, as success in the shorter periods 
is obtained. You can teach those who are in the habit of holding 
their muscles tense, and of assuming strained attitudes, to relax 
them, even for short periods, and so, perhaps, in time, effect a 
decided improvement in these abnormal muscular habits. 

You can teach simple finger-and-wrist motions, and also direct 
coarser muscular movements later, which will relieve the nerve 
tension caused by the finer muscular movements. Those pa- 
tients who are engaged in one kind of employment pretty steadily 
should receive intelligent attention in the choice of their amuse- 
ments, so to see that different groups of muscles are brought 
into play than those they have already exercised. 



220 NURSING THE INSANE [Chap. XVI 

On days when it rains, or when for any reason your patients 
are prevented from going out of doors, try what you can do to 
give them some pleasurable exercise indoors. Unless you do, 
a fretful, peevish, quarrelsome time may be expected. 

A bean-bag exercise is an excellent thing ; even a pillow fight 
is better than less harmless altercations that will assuredly arise 
unless a legitimate outlet is provided for pent-up energy. Care 
must always be taken to prevent vicious patients from hurting 
others, or mischievous ones from carrying their fun too far, as 
they are often inclined to do. A crane walk is another means 
of getting plenty of exercise and lots of fun in the bargain. Have 
a certain number form in line and hop about on one foot, following 
the leader. As soon as the leader makes a mistake, he goes to 
the foot, and the next in line seeks to see how long he can hold 
his place. Or, try simple exercises that call for some rivalry, 
such as to see who can touch the toes without bending the 
knees, or simple arm-and-wrist movements ; various things can 
be devised which will benefit the health and cheer the spirit and 
make one and all forget the rainy or the inclement weather. 

Music and dancing, or- games, may be started, and a true spirit 
of fun and frolic indulged in. Do not be afraid to play when you 
play. Unbend and be as little children once in a while. A good 
charge nurse can even allow a little boisterousness to go on under 
her supervision, without relaxing the necessary discipline of her 
ward, for she knows that a play spell is as necessary and as 
health-producing as food, and much more so than medicine. 
But do not let the patients feel that they are health-seeking in 
these things. Let them play for play's sake; thus will they get 
the truest benefit. 

Hunt for the humorous side of things. Laugh with your 
patients, and you will bind them to you ; laugh at them, and 
you will estrange them every time. 

Some of you may argue, " We are too busy with our ward 
work to find time to think of these things, much less to carry 
them out." Do you waste no time in idle talk, in profitless 
thinking, in selfish ends, in idly sitting about, and in novel read- 
ing (and not good novels at that) when on duty, and supposed 
to be exerting yourselves for the good of your patients ? If you 



Chap. XVI] AMUSEMENT OF PATIENTS 221 

can honestly say "no" to this, and still complain that you have 
no time for these things, then I withdraw my suggestions; 
but until you can, I earnestly urge you to consider them. 

Set your brains to work in some of the directions suggested — 
those that seem most applicable to you in your individual fields 
— and you will be surprised at your own ingenuity in devising 
means for other occupation and diversion. There are always 
some patients in your service that you can enlist in your projects. 
They may even carry them out, aided simply by your timely 
suggestions, while you are left free to work at other things. 
Start the ball rolling yourself, and they will often do the rest. 
Perhaps you will find only a handful at first to second your 
efforts. Do not be discouraged at this. Form a circle or a 
group of the acquiescent few, and little by little you will find 
others joining in, as their interests are awakened. Some who 
even scoff at first will later remain to play. 

An evening on the ward can occasionally be very pleasantly 
spent in playing school, having primary classes, classes in arith- 
metic, geography, reading, and spelling, and carrying it all out 
with a happy mixture of earnestness and fun that will send every 
one to bed feeling enlivened and rejuvenated to a surprising 
degree. Be careful to suit your questions and your plans to the 
individual patients as far as possible : ask easy questions of the 
backward or the illiterate ones, and take pains not to displease 
the irascible. Spelling matches and " spelling down " may 
awaken a very lively interest among patients and nurses as well. 

Energy and determination will do much to overcome the 
indifference and dullness and stubbornness of your charges. 
The various means, though not always obvious, are not past 
finding out, and the most signal success will be achieved 
by the one who ignores the discouraging features in the sit- 
uation and resolutely says to herself, " I will find a way, or 
make one." 

Never falter, if, after making vigorous efforts at rousing your 
patients, they lapse back into self-feeling and depression, and 
manifest delusions which you thought perhaps were being held 
in abeyance during the diversion. Each time you succeed in 
taking a patient out of herself you are starting up healthier 



222 NURSING THE INSANE [Chap. XVI 

brain impressions, and the renewal of these from time to time 
makes for health and sanity. 

You can sometimes get a depressed and agitated patient to 
smile at the absurdity of, for example, hearing grown people 
recite: — 

" Little drops of water, 
Little grains of sand, 
Make the mighty ocean, 
And the pleasant land " ; 

and then, as though ashamed of the temporary abandonment 
of her sadness, she may take up her lamentations with renewed 
vigor. But the momentary breaking through of that mental 
attitude has been salutary. Do not lose sight of the truth in 
the little drops of water rhyme when thinking of the rhyme itself. 

I have known a patient who believed it was her duty to sit on 
the floor by the hour and call through a crack in the door to 
imaginary people outside to carry out her numerous orders for 
saving the world, to be taken out for a carriage drive so against 
her will that it took two nurses to put and hold her in the car- 
riage, and yet after driving awhile get so interested in the world 
around her as to abandon entirely the giving of orders, and 
talk with intelligent delight of all that she saw and heard. Just 
as she was about to return to the ward, she said remorsefully, 
" Oh, there ! I've been enjoying all this, and forgot to save the 
world! " It is just this forgetting on their part that you want 
to bring about often and often, and as a little water wears 
away a stone, the new and healthy impressions will become a part 
of their mentality, and perchance restoration to a normal men- 
tality will follow. 

If Krafft-Ebing, the brilliant psychiatrist and gifted physi- 
cian, could spend entire afternoons in the garden with restless 
patients, if he could give his valuable time to play to them even- 
ings on the piano, is it not incumbent on you, as nurses whose sole 
duty in this field is the welfare of your charges, to marshal what- 
ever resources you have at command and use them for the good 
of your patients ? 



CHAPTER XVII 

SLEEP AND THE CONDITIONS WHICH FAVOR IT! DUTIES OF 
THE NIGHT NURSE 

Sleep is a state of more or less complete unconsciousness which 
admits of needed rest to the brain, but allows the nutrition of the 
body to continue. All animals and all organs must have periods 
of rest to counterbalance periods of activity ; repose must suc- 
ceed action in muscle and gland; between each breath the 
respiratory apparatus enjoys a brief pause ; even the heart rests 
between beats. These periods of rest in the various tissues and 
organs are recuperative or building-up periods, and in none of 
the organs are such periods more important than in the brain. 

The modern tendency is to regard sleep almost as an instinct, 
since it comes to us without our having been taught it, and 
without our realizing the purpose it serves. To regard it so, 
and to provide for its regular recurrence as one of the vital 
functions, is conducive to securing it in sufficient quantities to 
meet our needs. 

In sleep we are unconscious; the unconsciousness is brought 
about by a lessened activity in the cells of the brain cortex. We 
breathe more slowly and deeply when asleep than when awake, 
and the secretions are diminished in amount; for example, the 
tears : when we get sleepy the eyes feel dry, consequently, on 
waking, the natural thing is to rub them. The pulse rate is 
decreased during sleep, and the output of carbon dioxide is 
decreased also. It is probable that the blood vessels dilate 
during sleep, thus receiving more blood, while a smaller amount 
than usual flows to the brain. Aside from the above-mentioned 
accompaniments of sleep, the bodily activities go on much the 
same as in the waking state. It is chiefly the brain cortex 
that sleeps while the other organs are awake. The brain cortex 

223 



224 NURSING THE INSANE [Chap. XVII 

does not fall asleep all at once. Sleep creeps over one gradually ; 
the power to make voluntary movements is lost first, and last, 
the power to hear things, while just the reverse is true on waking. 

In dreams the brain cortex is not entirely at rest as it is in 
dreamless sleep, but, the judgment being in abeyance, all sorts of 
incongruous ideas may be presented to the mind without being 
rejected as incongruous. 

Somnambulism and dreams are both differing degrees of sleep. 
In dreams, as we have said, the forebrain is still partly active, 
but since the power of judging is in abeyance, and the power of 
voluntary movement is lost, we may seem to be in all sorts of 
distressing predicaments, and we suffer real discomfort from 
inability to extricate ourselves from these supposed conditions. 
We all know how it feels in nightmare to want to move and to be 
unable to do so. In somnambulism the forebrain is less inactive 
than it is in dreams. It retains the power to excite reflex actions, 
although the sensorium is still asleep. In this condition the per- 
son can execute many ordinary movements, can walk and talk 
and carry on a conversation, yet is incapable of distinguishing 
between external impressions and ideas or memories. This is 
why, in the somnambulism due to hypnotism, ideas presented to 
the mind by another seem like realities — why, for example, 
if the hypnotist says to one in a somnambulic state, " There is a 
scythe, go and mow that grass," the duped subject will go and 
lift an imaginary scythe and mow imaginary grass, much to the 
amusement of the on-lookers. 

Persons differ greatly in the amount of sleep needed, the dif- 
ferences being dependent upon age, temperament, the demands 
made upon the brain, the occupation, the race, and the climate. 
On an average, an infant needs from fourteen to sixteen hours, 
children need from ten to twelve, adults about eight hours, and 
elderly persons about six. 

When one wakens tired, it is a danger signal that nature has 
not done her recuperative work well. From refreshing sleep to 
insufficient sleep, or almost no sleep at all, one goes by varying 
stages, according to the conditions giving rise to these disturb- 
ances. 

Insomnia is the condition of insufficient or restless sleep or 



Chap. XVII] DUTIES OF THE NIGHT NURSE 225 

entire absence of sleep. This is one of the most common symp- 
toms in the beginning of nervous and mental disorders. And, 
strange to say, in many cases the more the patient needs sleep, 
the less need he feels for it. His brain is overactive, and he 
resorts to all sorts of things at night rather than cease his activi- 
ties and let Nature bring her restorative processes to his aid. His 
tendency is to carry activity to the fatigue point, and the evil 
effects are seen in lack of poise, unstable emotional conditions, 
and later in graver nervous and nutritional disorders. 

Many neurasthenic patients have such unrefreshing sleep that 
they think and assert that they have not slept for weeks, but it is 
an established fact that one cannot go longer than three weeks 
without sleep any more than he can without food, and few per- 
sons probably go that length of time. Insomnia often gets to 
be a habit just because of unwise ways of living and of regulating 
one's life. Persons with a hereditary tendency to insanity are 
especially prone to develop the habit of insomnia. In anemic 
conditions, patients are often sleepy during the day and wide 
awake at night. Insomnia may be due to other circulatory 
disturbances, heart disease, hardened arteries; to toxic con- 
ditions, such as poisoning by lead, malaria, drugs, stimulants, or 
to autotoxic states, as in gout and uremia. 

The nightly restlessness and the insomnia of aged patients are 
symptoms due to senile changes in the blood vessels, and annoying 
as they are, should be dealt with patiently, since the manifesta- 
tions growing out of these conditions are things for which the 
patients are in no way responsible. Such persons need to be 
soothed and appeased as one would a tired, restless child. Mas- 
sage is often helpful in these cases. 

Strong tea and coffee taken at night are responsible for the 
overactivity in the thoughts that prevent many persons from 
dropping off to sleep. 

The victims of morphia and of other drugs are proverbially 
troubled with insomnia. They want to turn the night into day, 
and the day into night. Hydriatric measures and massage will 
do much to alleviate this insomnia. Sometimes sponging with 
warm water to which vinegar has been added proves soothing. 

In all cases of sleeplessness or of deficient or unrefreshing 



226 NURSING THE INSANE [Chap. XVII 

sleep we must search for the cause, which is likely to be a differ- 
ent one in each person. After having made all preparations for 
sleep that would naturally favor it, if it still refuses to come, one 
needs to search into individual conditions to find what is pre- 
venting it. And it is only fair to say that in some cases, in spite 
of persistent efforts, certain patients will continue to be wakeful 
and restless. But these cases should be reported at the time, 
shifting the responsibility on the physician; do not wait till he 
learns it the next morning on the night report. Some patients 
who habitually waken at 3 or 4 a.m. will, if given a cup of hot 
milk, soon drop off to sleep again. 

We favor sleep by certain preparations for it, by accustoming 
ourselves to go to bed at a certain hour, by removing constrictions 
from the body, by darkening the room, by lessening all possible 
noises, by securing fresh air in the room, by relaxing the muscles, 
by closing the eyes and withdrawing the thoughts from the day's 
activities, or from plans for the future, and by breathing slowly 
and deeply, and waiting tranquilly for the drowsy feeling to 
overtake us. Light and noise are potent agents in keeping away 
sleep, as the various stimuli they arouse affect in turn the 
would-be sleeper. Monotonous sounds, however, such as the 
ticking of a not too insistent clock, the droning voice of a 
reader or speaker, the hum of bees, and the sound of ocean 
waves, are often conducive to sleep; monotonous passes, or strok- 
ing of the brow or of the arms, and swaying of the body, as in 
rocking, are well-known aids in some instances. 

We have said that sleep is as necessary to the brain as rest is 
to the muscles, but it is also true that exercise is as necessary to 
the brain as is rest; some cases of nervous restlessness resulting 
in insomnia may really be due to the fact that the brain has been 
too sluggish, that it has not exercised itself enough to earn the 
right to sleep, although the cases of insomnia due to this cause are 
probably comparatively few in number. 

To bring about refreshing sleep it is necessary to undress the 
body and undress the mind; to remove the traces of the day's 
soil from the face and hands, at least, and the traces of the day's 
cares from the soul; to brush the hair and arrange it in such a 
way that it will not interfere with an easy position of the head, 



Chap. XVII] DUTIES OF THE NIGHT NURSE 227 

and to brush from one's thoughts the things that annoy, by 
refusing to let them occupy the center of consciousness. The 
extremities should be warm and the head cool, the bowels and 
bladder should be emptied, but not necessarily the stomach. 
It is difficult to get to sleep on " an empty stomach," or at least 
when the stomach has been empty so long that gnawing and 
hunger are felt. At the same time an overloaded stomach is not 
conducive to refreshing sleep, although that condition makes one 
sleepy. With these preparations and a well-ventilated, quiet, 
darkened room, a comfortable bed, neither too much nor too 
little clothing, and not too high a pillow, the conditions are 
favorable for sleep. 

When we speak of undressing the mind, we mean to lay aside 
cares, to withdraw interest from the external world, and so allow 
the higher brain centers to become inactive. To this end it is 
not well to prolong one's work up to the hour of retiring. There 
should be an interval of brief recreation, at least, between work 
and sleep. If one's work is sedentary, a brief walk or some 
muscular activity is desirable; especially if it is mental, is it 
necessary to " shut up shop " and relax and play in some way 
before sleep is sought. 

It is a great mistake to select interesting and stimulating 
reading in the late evening hours, since, as has been suggested, 
this is the time when efforts should be made to withdraw every- 
thing that tends to brain activity. Those who are given to hard 
muscular work during the day seldom have difficulty in wooing 
sleep. 

It is important what position one assumes in bed. In the first 
place, one should be sufficiently but not too warmly covered. 
Warmth and lightness are the desirable qualities in bed cover- 
ings. The bedding should be so arranged at the foot of the bed 
that it does not draw over the toes. Then there should be com- 
plete relaxation of the body. Some persons have the habit of 
lying with the arms above the head — a habit which should be 
broken, as should also that of lying on the back. Lying on the 
abdomen, with the face resting on the arms, for a brief rest, is not 
a bad position, but the most favorable one for prolonged sleep 
is to lie on one side, with the head only slightly raised on a pillow, 



228 NURSING THE INSANE [Chap. XVII 

with the face so turned up as to free the cheek from the pillow's 
pressure, and so that the full face is exposed to the air; the arms 
and legs and even the fingers should be as completely relaxed 
and in as comfortable a position as possible. Watch a sleeping 
infant in the perfect relaxation that it unconsciously enjoys, and 
you will see the best example of real relaxation. Instead of this 
letting go that we can see in almost any sleeping child, most of us, 
unless we are careful, find that we assume positions in bed that 
keep muscles contracted that we should relax; we clinch our 
hands or set our jaws tightly together, or hold ourselves on the 
bed instead of giving our bodies up to the bed and letting it hold 
us. When we find that this is the case, we need systematically 
and persistently to cultivate the habit of letting go, to direct our 
thoughts to securing muscular repose and slow and deep breath- 
ing, and we will be surprised to see how these very measures will 
help us to brush aside the thoughts and cares that have been 
chasing sleep away. On no account should one cover the head 
with the bed clothing. This is a habit among a certain class of 
insane patients that should be broken up by patience and per- 
sistence on the part of the nurse. 

Night Nursing. — The position of night nurse is one of the 
most important in the entire nursing service. Such nurses are 
put on their honor, and are intrusted with graver responsibilities 
than are any of their associates. Such a trust will always make 
a conscientious person more than ordinarily careful to be alert 
at every turn, to bring to bear his best judgment, to summon 
all the resources at his command, to the end that these duties 
intrusted to him shall be fulfilled in a satisfactory and com- 
petent manner. 

Cooperation between day and night nurses is especially impor- 
tant, and the friendliest cooperation. The utmost pains should 
be taken by both forces to make the work of each as easy as 
possible; to see that each is regularly and fully informed of all 
that has to do with the understanding and the discharge of the 
other's duties. Sufficient supplies of bed linen and clothing, 
of medicines, etc., should be left for the night nurse, who should, 
on the other hand, exercise the utmost care to prevent patients 
from soiling their beds or clothing, by timely care and attention 



Chap. XVII] DUTIES OF THE NIGHT NURSE 229 

to getting them up as often as necessary, for individual cases, 
during the night. One can to a great extent gauge the super- 
vision of the night nurse in this respect; by the number of sheets 
found soiled in her department in the morning, especially if they 
are greatly in excess of those used by the same patients during 
the day. The care of the mattress and the pillows is especially 
important, and the nurse who takes pride in preserving these dry 
and clean, by keeping the rubber sheets in place, and changing 
her patients as often as they need it, and always washing and 
carefully drying them when they need changing, is usually one 
who takes pains to break up uncleanly habits by getting the 
patients up frequently, if need be, rather than let them habitually 
soil the bed. In all these ministrations it is important that the 
work be carried on as quietly as possible. It is not permissible 
to turn on all the lights to bring this about ; no more lights 
should be used than are absolutely necessary to do the work. The 
general night watch, who visits the dormitories and rooms every 
hour of the night, needs to attend carefully to patients needing 
attention of any kind — a drink of water, a glass of milk, hot- 
water bag, etc., and to empty regularly any vessel containing 
fecal matter. The day nurses should take especial care to report 
to the night nurse transfers and admissions, with the full names 
and the significant facts concerning them, whether suicidal, 
or dangerous to others, mischievous, unclean, or ill; with direc- 
tions as to nourishment, medicines, or special nursing; what 
observations the physicians are especially concerned about. 
In short, the harmony and spirit of helpfulness between the day 
and night assistants should be so close that it amounts practically 
to continuous observation. There should be no such excuse 
offered as, "I don't know; the night charge left no account of 
what happened," or " I received no instructions about the case 
from the day nurse, and had to do the best I could," and the like. 
New cases of illness arising during the day or night, with full 
particulars as to the symptoms and the nursing, assaults, ac- 
cidents, bruises, special events of any kind — all should be fully 
talked over by the day nurse in turning her ward over to the 
night charge, and by the night nurse in turning her ward over to 
the day charge. It is not enough that the night nurse report 



230 NURSING THE INSANE [Chap. XVII 

the events and conditions on the blanks furnished for the purpose ; 
these of necessity are limited as to space, and the nurses can go 
into necessary details in a verbal report that will enable the one 
who talks with the physician or supervisor to give information 
that could not always be put on the night reports. 

Night reports, however, should be just as fully and neatly 
and legibly made out as possible, and in case of any affair of 
serious moment, if the blank does not furnish sufficient space for 
its recording, in addition to her verbal report to the day charge, 
the night nurse should write out for the physician an account on a 
separate paper, always dating and signing the paper, which is to 
show the ward location also. The night reports now in use in 
the State hospitals call for a list of patients, with spaces to be 
filled out each hour from 8 p.m. to 6 a.m., stating whether the 
patients were asleep or awake, restless, noisy, violent, whether 
wet or soiled, whether they have had convulsions, or have vom- 
ited, and so on. Under the heading of special incidents you 
can put accounts of other conditions not provided for by the key 
of letters at the head of each night report. The other things 
called for by the report, the admissions, transfers, deaths, de- 
tails concerning destructive patients, the ward temperature at 
the hours specified, all should be conscientiously and properly 
filled out. 

Night nurses are expected to leave the hospitals in order, all 
soiled patients cleaned, dried, and changed, all vessels emptied, 
the beds of the patients who have arisen properly aired, the room 
well ventilated, and the dishes that have been used throughout 
the night clean. 

The night nurse should see to it that she is as quiet and unob- 
trusive in dress and movement at all times when on duty as it is 
possible for her to be — in voice, in step, in the moving of dishes 
or furniture, in the rattling of keys, in the running of water, in 
the use of lights, and even in the turning of the leaves of a book 
or a magazine. She should avoid reading newspapers when on 
night duty, as these cannot be turned quietly. In all her min- 
istrations to waking patients she needs to keep constantly in 
mind the effort to reduce all noise or disturbance of any kind to 
a minimum, to the end that others not awake may not be dis- 



Chap. XVII] DUTIES OF THE NIGHT NURSE 231 

turbed, and that those who are wakeful and restless may be 
quieted so that sleep may come to them also. Gowns and aprons 
too stiffly starched, and squeaking shoes are especially to be 
avoided. Felt shoes are greatly to be preferred by night nurses, 
or at least soft, quiet shoes, with rubber heels. Keys should be 
inserted in locks quietly, drawers and medicine closets, doors 
and windows opened with the least possible noise, and when it 
is necessary to speak to wakeful patients, it should be done in a 
low, soothing, tactful way, bearing in mind continually that the 
nurse can do much, in time, by the influence of her own gentle 
example, even with disturbed patients, to bring about a quiet 
ward, and a habit of consideration for others in those who 
themselves cannot sleep. It is inexcusable to scold or threaten 
troublesome patients; it not only defeats the purpose of securing 
a quiet ward, but is a thing that will not be tolerated by the 
hospital authorities, and is beneath the dignity of any one as- 
piring to be a nurse. 

The heating and the ventilation of the wards at night are 
especially important, and it is largely owing to the nurse's effi- 
ciency in regulating these matters that the restful sleep of many 
of her patients is due. She should be so warmly clad herself 
that she can be comfortable in the prescribed nightly tempera- 
ture of the wards, and not expect to keep the rooms so warm 
that she, sitting around in a thin gown, will be warm as toast, 
while her patients are too warm to sleep. 

A competent night nurse will not suffer patients under her care 
to be noisy, disturbed, and wakeful without constantly exerting 
herself to seek the cause of such disturbance, remedy it if pos- 
sible, and report such conditions if she cannot, so that other 
measures may be taken for their relief. 

Wakeful patients may often be soothed into a restful sleep by 
very simple measures on the part of the nurse. New patients 
can be comforted and reassured, hungry ones fed, untidy ones 
made tidy, disturbed ones appeased by some little suggestion 
or diversion, quarrelsome ones separated, restless ones made less 
restless by attention to the regulation of the temperature, the 
bedding, whether too much or too little, by an evacuation of the 
bladder or of the bowels, by a drink of water, a slice of bread and 



232 NURSING THE INSANE [Chap. XVII 

butter, by a glass of hot milk, by a cold compress on the forehead 
or around the wrists, by a hot-water bag to the feet if they are 
cold, or to any part in pain, by soothing stroking of the brow and 
limbs, bathing hands and face in alcohol and water, warm or 
cool sponging of the spine, or rubbing of the back (avoiding 
talking meanwhile), by baths or packs if ordered by the phy- 
sician, and in countless other thoughtful ways that will suggest 
themselves to the conscientious, alert, resourceful night nurse. 

Sometimes going to a wakeful patient and sitting by the side 
of, but not on, the bed, talking to her in a low tone, or letting her 
talk for a little while, will allay the nervous restlessness that is 
preventing sleep, especially if there are troublesome thoughts 
from which she needs to be diverted. Stroking the temples or 
pressing the fingers on the eyeballs, with a quiet command to 
sleep, will prove helpful to some patients. In all stroking move- 
ments avoid talking or unnecessary movement. 

Narcotics are never to be administered except on the order of a 
physician, and on no account are medicines prescribed for one 
patient to be given to another unless so ordered. Patients are 
never to be wakened to administer medicine to them unless so 
specified by the physician. Especial care needs to be exercised 
at night, because of the subdued light, in reading the directions 
and administering medicines exactly as they are prescribed. 

If a patient's wakefulness is due to pain, the nurse should 
do all in her power to ascertain the seat of the pain, and its 
cause, if possible; whether from headache, toothache, indigestion, 
hunger, menstrual cramps, diarrhea, etc. She should make 
sure that the bed is as comfortable as possible, dry and clean, 
free from wrinkles and crumbs, that the eyes are shaded from 
the night light, that no flapping window shades, rattling windows, 
defective traps, dripping water faucets, creaking doors, or any 
unnecessary noise is helping to keep the patient awake. At 
the lunch hour the nurses should be particularly careful not to 
waken patients by their talk, or by the rattling of dishes. In- 
considerateness in this respect is inexcusable. Weak and aged 
patients, and those especially susceptible to draughts, should 
be given as protected places in the room as possible, and with 
those patients who object to the necessary ventilation, especial 



Chap. XVII] DUTIES OF THE NIGHT NURSE 233 

pains should be taken to appease them and allay their fears and 
objections rather than to antagonize them. This can often be 
done by explaining to them that you will see that they shall not 
take cold, but that in a room with so many persons, or even in 
any sleeping room, it is necessary that an abundance of fresh 
air comes in at night, so that sleep will be more refreshing, 
and that their bodies will be built up while they are sleeping. 
If you go about it in the right spirit, you will be surprised to see 
how many patients you can persuade to listen to reason, but 
if you ignore their complaints, or brusquely reply to them, you 
can hardly expect amiability and docility on their part. 

Patients with visual hallucinations and illusions should not 
be in a room entirely dark at night, as these symptoms are more 
vivid in a dark room and at night than under other conditions. 
This applies especially to alcoholic cases, e.g. delirium tremens. 

The night nurse has exceptional advantages for the observa- 
tion of her patients, since the many distractions of the day are 
absent. She can often note and describe attitudes and habits, 
the character of the delusions, the stream of talk, the character 
of the sleep, whether quiet or disturbed, whether there is start- 
ing in the sleep, or talking, or troublesome dreams, any unusual 
positions of the body, whether the patient is very easily awak- 
ened, what his condition seems to be on waking, etc. Patients 
who waken in a frightened condition, often with the fears left 
from a troublesome dream still remaining with them, should 
receive especial care from the nurse to divert and quiet them. 
Epileptics need especial watching, from the beginning of the 
convulsion till stupor supervenes. The nurse should never 
grow so callous to these occurrences that she fails to observe 
the patient closely during the convulsion, and to render what 
aid she can. 

The nurse needs to remember that in the early morning hours, 
from 1 to 4 a.m., the vital powers are at the lowest ebb, and that 
her feeble charges need especial care at those times — more 
heat, more coverings, hot-water bags to feet, hot milk to drink, 
but not less air. 

If the nurse has difficulty in keeping awake, and there is 
absolutely no patient to whom she can minister, since all are 



234 NURSING THE INSANE [Chap. XVII 

sleeping, or at least quiet, she can practice counting the pulse 
or the respirations of such patients as will not be disturbed by- 
such a procedure, and so be acquiring more proficiency in this 
direction, at the same time that she guards herself from a grave 
infringement of the rules; to sleep on duty is a grave misde- 
meanor in a night nurse for the insane ; the position is one of 
great responsibility, constant watchfulness is needed to guard 
against accidents of various kinds, against assaults upon others, 
against suicides, to say nothing of the supervision necessary to 
prevent the destruction of property, and to guard against and 
to break up habits of uncleanliness. A night nurse who fails 
to take her proper amount of sleep in the daytime, and who 
puts in that time in work or play when she should be asleep, is 
not acting honorably with the institution for which she works, 
for she is thereby unfitting herself for the proper discharge of 
her duties, and even with the best intentions to keep awake, she 
is in danger of succumbing to the demands of cheated nature. 
When she does this, even if she is not discovered, her work can- 
not fail to deteriorate, and her own self-respect to diminish. 
Since so much is intrusted to her, it is highly important that she 
preserve her health by plenty of sleep, good food, and daily ex- 
ercise, and that she bring to her work each night a sympathetic 
interest in her various charges, an intelligent understanding of 
their needs, and a ready intent to help them in every way that 
lies in her power. 

The means for fire protection, the hose closets, the regularly 
filled bath tubs for a ready supply of water in case of emergency, 
the care of matches and of lanterns, the safeguarding of medicines 
and disinfectants, and of all appliances or contrivances whereby 
patients could harm themselves or others — attention to these 
also constitutes a part of the exacting duties of night nurses. 

A few words are necessary about the early morning hours on 
the wards. Many patients waken early, and unless prevented, 
wish to get up and dress. It is also a fact that the night nurse 
has many duties to attend to in order to leave the patients and 
the ward in proper condition for the day nurses, and after the 
long hours of the night she welcomes the stir and bustle of the 
morning that show that her long vigil is nearing an end. But 



Chap. XVII] DUTIES OF THE NIGHT NURSE 235 

here she needs to remember how very important it is to her 
patients that they be allowed to sleep as late as possible, and 
that all her necessary activities be carried on as quietly as possible 
so that no patients be cut short of the all too small allowance 
of sleep accorded them. Patients who tend to waken too early 
should be required to remain in bed until the time for rising 
arrives, and even then, if others are sleeping, or would sleep if 
the ward were quieter, the conscientious nurse will use every 
effort in her power to secure them this additional sleep. When 
you rob a nervous or mental patient of sleep, you are retarding 
if not seriously prejudicing his chances of recovery, while in 
chronic cases you are fostering conditions that increase dis- 
comfort and exaggerate nervous excitability. 

We can perhaps sum up briefly the duties of this position by 
saying that they consist in maintaining a vigilance that never 
sleeps, but that is quietly observant in ascertaining and prompt 
in applying measures for promoting sleep in the patients. 



CHAPTER XVIII 

A TALK ON PSYCHOLOGY 

Psychology is the science of mental life. It deals with all 
manifestations of the mind, such as feelings, desires, reasonings, 
decisions. In order to experience any of these phenomena, we 
need first to receive impressions through our sense organs and 
to have them registered in our brains. On the other hand, 
various mental states that we experience occasion bodily altera- 
tions, such as changes in the caliber of the blood vessels, in the 
rapidity of the heart beats, and in the secretions of the various 
organs and glands. We thus see how body and brain act and 
react upon each other, and cannot therefore be considered 
separately. 

We are, in reality, the sum of all that we have seen, heard, 
smelled, tasted, and felt since our conscious life began, plus our 
inheritances from all the lives that have preceded ours as our 
progenitors, and plus the results of our response to all that we 
have experienced. I shall try to make plain farther on why 
this is true. 

Many of our acts which are apparently performed uncon- 
sciously were originally the result of conscious effort, but have 
been performed so often that the habit of doing them has resulted, 
and in time we come to do them more or less automatically. 
Standing, walking, dressing and undressing, writing, speaking, 
piano playing, knitting — these are but a few of the many 
automatic acts of everyday life. 

Inanimate objects, that is, things without life, can perform no 
intelligent act ; but living beings, in proportion to their develop- 
ment, possess the power to reach certain ends by varying their 
conduct to suit the conditions and obstacles that confront them. 
Professor James illustrates this difference very forcibly when he 



Chap. XVIII] A TALK ON PSYCHOLOGY 237 

speaks of how iron filings behave when a magnet is brought near 
them, how they will even fly through the air for a certain distance 
and cling to the magnet, but how, if a cardboard be placed over 
the pole of the magnet, the filings will stick to that card forever, 
without knowing enough to pass around the card and get in 
contact with the magnet that is attracting them. But Romeo 
and Juliet, as he points out, while drawn to each other as the 
filings are drawn to the magnet, learn to move in circuitous lines 
if obstacles to straight ones are raised, learn to scale walls and 
find each other in spite of opposition and difficulties — all be- 
cause they are capable of conscious intelligent acts. The move- 
ment of the filings toward the magnet is a mechanical act, the 
progress of Romeo toward Juliet is an intelligent one (although 
not exactly a wise one, as the resulting tragedy proves). In 
a lesser degree than Romeo's aggressive actions, the acts of the 
lower order of animals are intelligent in so far as they are per- 
formed for the sake of their result, although many of these seem- 
ingly intelligent acts are the result of inherited instincts, and 
are consequently more or less automatically performed. We 
see this same automatic intelligence in certain plants as well 
as in animals — creeping vines lifting themselves to the rough 
surface of a wall to which they can cling for support, or a po- 
tato sprout sending out its long arm to reach the light and air. 
These, of course, cannot be called intelligent acts in a psy- 
chological sense. Only, then, such acts as are done with a con- 
scious end in view, and show that choice has been made in the 
means employed, are properly called intelligent acts, and only 
beings capable of intelligent acts may be said to have mind. 

The brain is the organ of the mind; it is material, while the 
mind is immaterial. In other words, the brain has a certain 
structure made up of matter, while mind is something we cannot 
see or appreciate by any of our senses; it can only be known to 
us through its operations — through evidence within ourselves, 
and to some extent through our observations of its operations in 
others. What we learn of its workings in others is learned objec- 
tively; what we learn by studying our own minds during and after 
operation, by self-analysis, or introspection, is learned subjectively. 

Mind shows itself by means of its three faculties: thinking, 



238 NURSING THE INSANE [Chap. XVIII 

feeling, and acting. These mental processes are accompanied 
by certain activities in the nervous system, and the degree of 
mental activity is curiously dependent upon the disposable 
energy of the brain, while the brain is dependent upon the 
condition of the nervous system as a whole; so that disease, 
fatigue from severe brain work, or loss of sleep, or exhausting 
emotions, affect the power of work of the brain, and so affect 
the workings of the mind. 

The kingdom of nature is divided into three great classes, 
mineral, vegetable, and animal, to go from the lowest to the 
highest. There is an old statement as follows: "Stones grow; 
plants grow and live; animals grow, live, and feel." This gives 
us broadly the degrees of difference to be met in the three king- 
doms. Stones grow by the process of accretion — an adding 
on of material from without, although they belong to the inani- 
mate part of nature; plants grow and live because they have 
what we call the vegetative functions — they have the power of 
inherent motion, they can appropriate nourishment from their 
surroundings; their life is carried on by the processes of ab- 
sorption, circulation, respiration, and reproduction; but animals 
feel as well as grow and live, and this because they have a nervous 
system; in some, of a very rudimentary sort, in the higher orders 
of a very complex structure. Pluck a rose from a bush, and the 
other roses go on blooming, all unconscious that a part has been 
severed from the whole ; but bruise merely the ringer of a man, 
and every part of his body seems aware of the violence done him. 
This awareness is brought about by the nervous system, which 
brings all parts of the body into relation with one another. 
Nerves which are stimulated by the bruise convey the excitement 
to the nervous centers, the commotion thus set up there dis- 
charges itself through another set of nerves into muscles which 
move the limb in a protective way in order to get it away from 
the thing that is bruising the finger. When the response of 
a part takes place without the intervention of the will, we call 
the act a reflex act; when it is a result of a consciousness of the 
purpose to be attained and a command of the will, it is voluntary. 
Many reflex and voluntary acts become merged into each other, 
and are called semi-reflex acts. 



Chap. XVIII] A TALK ON PSYCHOLOGY 239 

The lower centers of the nervous system act in response to 
whatever excites them at the present time, while the higher 
centers, which are believed to be the seat of memory, act from 
groups of former sensations received and from considerations 
concerning these former sensations, with a weighing of the 
probable results of a contemplated act. 

Victor Hugo's hero, Jean Valjean, well illustrates in one in- 
dividual these two extremes. Early in his career, in a moment 
of sudden temptation, he gives way to the animal desire for food 
for himself and seven little children dependent upon him. He 
steals a loaf of bread, is caught in the act, sent to the galleys, 
and suffers a long train of tortures and misery as a result of his 
theft. Later, when he has worked out his long sentence and is 
free, but with the stigma of a convict still upon him, he is be- 
friended by a good bishop who gives him shelter and trusts him 
with the freedom of the house, in which is kept a lot of costly 
silver plate. He awakens in the night and thinks of his sore 
needs, of how much money the silver would bring him; he under- 
goes a terrible temptation, torn between his desire to be worthy 
of the trust the bishop places in him and his need of the money. 
He does not quickly yield to the temptation as he did in the 
beginning of his career; memory recalls to him the long train of 
consequences of that first theft ; his partly awakened moral 
nature makes him aware of the baseness of his contemplated 
deed, but as yet the lower centers are more in the habit of being 
used than the higher ones, and so the impulse to act follows the 
path that is well worn in the nervous system, instead of the 
unaccustomed higher one. Jean Valjean steals the silver plate 
from his benefactor, and soon finds himself again in wretchedness 
as a result. We cannot here trace his career, but a study of 
that wonderful novel of Hugo's, Les Miserables, will show you 
how the man's higher centers gradually assumed control over 
the lower, how he was gradually able to withstand temptations 
which he first yielded to, how resistance strengthened him in 
well-doing, and how the ennobling effects of self-discipline and 
of doing good to others made him stronger and stronger, going 
on from victory to victory, till one can hardly recognize the 
desperate criminal of the beginning of the story as the redeemed 



240 NURSING THE INSANE [Chap. XVIII 

and regenerated hero at the end. The reconstruction of the 
character was a slow and painful process. It was brought 
about by the creation of new and right paths in the nervous 
system; by suppressing lower impulses and harkening to the 
higher ones; by overcoming evil with good. 

Our whole life is made up of two classes of things — impres- 
sions and movements — impressions made upon the nervous 
system, and movements resulting from these impressions. It 
can then be easily seen how important it is that we put our- 
selves in the way of receiving as many favorable and helpful 
impressions as possible, and, on the other hand, how supremely 
important it is that we react in the right way to whatever im- 
pressions come, refusing to be dominated by those that would 
lead to ignoble acts, and taking advantage of all that stimulate 
to noble ones. 

We have previously spoken of the faculties of the mind as 
thinking, feeling, and acting. In order to think about an object, 
it first has to be sensed, perceived, remembered, and reasoned 
about. In order to feel what is implied in the words sorrow, 
joy, fear, anger, jealousy, love, a pleasurable or painful state of 
mind, an emotion, is experienced. In order to act, we deliberate 
upon what we have already thought and experienced, and we 
decide to do or to refrain from doing a given thing. 

We need to be here reminded that the nervous system is made 
up of nerves and nerve centers; that the nerves are of two kinds, 
the sensory or in-carrying nerves, which convey impressions 
received by the sense organs to the nerve centers; and the motor 
or out-carrying nerves, which convey the impulses that cause 
the muscles to respond to the impressions that have been re- 
ceived ; the nerve centers themselves consist of sensory centers 
which receive excitation from without, and motor centers which 
excite the out-carrying nerves. 

There is a great difference in individual minds in their sus- 
ceptibility to impressions, in their power of attention to them, 
in their ability to compare and discriminate between various 
impressions, in their emotional susceptibility, and in their manner 
of responding to received impressions. There is also a great 
difference in any one mind under varying conditions. 



Chap. XVIII] A TALK ON PSYCHOLOGY 241 

In order to know anything about the simplest object, certain 
successive stages have to be traversed. Through some one of 
the five senses an impression of that object has to be conveyed 
to the mind. This we call a sensation. This sensation is 
followed by an awareness of the object, a conscious attention 
to it, which is called perception. This is a much more complex 
process than sensation, as it necessitates the grouping together 
of previously received sensations, regarding them in their various 
relations, and apprehending them as immediately present out- 
ward realities. After perception comes the image-making in 
the mind of what the mind has perceived — the imagination. 
Finally we have the thought or knowledge about the object. 
This consists in forming general notions about what we have 
already perceived and pictured (conceptions), of forming opinions 
and coming to conclusions about it (judgment), and of, perhaps, 
combining these opinions and forming opinions about similar 
objects (reasoning), since what we learn of one object gives us 
a clew as to what we may reasonably infer about a similar object. 

Upon the keenness of the perceptions, the retentive power, 
or the ability to store up and revive the products of former 
impressions, and the ability to utilize them in the thought life, 
depends the efficacy of the individual so far as his intellect is 
concerned. Brain power is increased through exercise in two 
ways : in some way that we do not understand, all brain activity 
reacts upon the particular structure engaged, modifying it so 
that it is disposed to act in a similar manner again; then there 
is a tendency for different parts of the brain which are exercised 
together to fall more and more readily into this cooperative 
action. This is what is meant by paths being formed in the 
nervous system, along which impressions and impulses flow more 
and more readily as they become worn by use. 

By attention we mean the active interest that the mind takes 
in a given thing at the moment it is being regarded. The 
power of attention differs greatly in different persons and in the 
same person at different times. We have to attend in a general 
way to a great many things at once, and all the things that are 
receiving attention from us at a given moment make up our 
consciousness at that moment. Some are more sharply per- 



242 NURSING THE INSANE [Chap. XVIII 

ceived than others, because on them we concentrate our atten- 
tion. Some things, we say, we regard subconsciously; that is, 
they occupy the outer rim of our consciousness instead of the 
center of it, just as when we glance at any one object we see that 
especial object with distinctness, surrounding objects with less 
distinctness, and objects farther removed from it with still less 
and less distinctness. So in our consciousness we speak of the 
things that occupy our immediate attention, and others of which 
we are clearly aware, even though regarding them less intently, 
as being parts of our conscious life, and those that occupy the 
outer rim of our mental field of visions, which are but dimly 
perceived and attended to, as being parts of our subconscious 
life. This closeness or vagueness of attention applies to our 
sensations, to our intellectual activities, to our emotional life, 
and to our actions. We are continually bringing some things 
into the center of our mental field of vision and crowding others 
farther and farther out toward the rim ; things are being shifted 
about as are the colored pieces of glass in a kaleidoscope, our 
voluntary attention answering to the hand that turns the in- 
strument. The things we see, or sense in any other way, have 
their direct influence upon us, then, in proportion as we heed 
them; the pleasures and the pains we experience take hold of 
us according as we fix our thoughts on them, or disregard them; 
the kindnesses of others, or the slights or injuries that we receive 
at their hands, affect us in so far as we look attentively at them, 
or look away from them; even our diseases, many of them, are 
capable of being pushed to one side, or of being the closest of 
companions, according to our manner of attending to them. 

We have previously learned that a sensation is a mental state 
resulting from the stimulation of the outer extremity of a sensory 
nerve. This stimulation or excitation has to be conveyed to 
the sensory center in the brain before the mind experiences 
the sensation. If the connection between the nerve extremity 
and the center is broken, no sensation can result. It takes 
a certain appreciable time for the transmission of the stimula- 
tion to the center and for its effect to be noted in whatever 
reaction takes place, although the reaction ordinarily seems 
instantaneous. Numerous experiments to determine the length 



Chap. XVIII] A TALK ON PSYCHOLOGY 243 

of time it takes for a muscular reaction to result, after a sensory 
impression has been made, have shown that this reaction time 
varies in different individuals, and with the same individual 
under different conditions. Aged and uncultivated persons, 
and children, are slow to respond ; practice in the application 
of any given stimulus brings about a more and more prompt 
reaction; fatigue lengthens the time, making one " retarded," 
as we say, while concentration of attention shortens the time, 
just as distractibility, or a "scatter-brained" way of regarding 
things, lengthens it. 

These reactions have been tested in regard to sound, light, 
electric-skin reactions, touch sensations, taste and smell reac- 
tions, and the like. Sound is more promptly reacted to than 
either sight or touch; taste and smell are slower than either. 

The regions of the skin where the stimuli are applied have 
much to do with the quickness or slowness of the reactions, 
the parts most abundantly supplied with nerve terminals being 
those that yield the speediest results. Intoxicants, coffee, tea, 
etc., alter the reactions, usually quickening them primarily. 
This is why brain workers so often resort to these stimulants to 
help them do their work. The tendency of alcohol is at first 
to quicken, then to lengthen, time reactions ; morphia lengthens 
them, also ether and chloroform; certain diseased states do also. 

By the term sensibility we mean the mind's capacity for being 
acted upon by the stimulation of the sensory nerves. 

Psychologists differ greatly in their use of the words sensation 
and perception; we cannot enter into these differences here, but 
will follow those who regard a sensation as being the reception 
in a sensory nerve center of an impression received from the 
outer extremity of a sensory nerve, while the perception of that 
impression consists in referring it to a given object. For example, 
a book is held before my eyes, and through the sense of sight 
I am made aware of its appearance. This appearance, as it 
is conveyed to the sensory center in my brain, constitutes the 
sensation; while my perception of it, or, in other words, my 
ability to project this sensation into the world outside of myself 
and connect it with the object (the book), is a rather complex 
process, and is dependent upon my having previously seen other 



244 NURSING THE INSANE [Chap. XVIII 

books, and of learning about them as regards form, color, size, 
feeling, etc. 

By sensation and perception, then, we mean processes in which 
we become aware of an objective world. If an object has a single 
striking quality, whether it be detected by the sense of sight, 
hearing, taste, smell, or touch, we note it as such, and as such 
we get a sensation of this quality. It may be the color, the odor, 
the noise; whatever it is, its distinguishing quality determines 
the force of the sensation. It may be a single sensation we 
get from a given object, or a combined one. If we feel a hot 
poker, we get the simple sensation of pain ; but if we see a poker 
under varying conditions, we get from time to time various 
sensations concerning it ; we see not only that at times it may 
be red-hot or white-hot on the end; we also see that it is long 
and round, that it has a handle at one extremity, that the handle 
is of wood, that the remaining portion is of iron; we learn that 
the wood has a certain feel, the iron another, and all the 
various sensations we have received concerning it make up 
what we call a percept of the poker; and the grouping of these 
sensations, discriminating them from other sensations and refer- 
ring these groupings to the object itself, we call a perception 
of the poker, which, it can be readily seen, is a much more com- 
plex process than any single sensation concerning it. The more 
we know of any object, then, the more keenly aware we are of 
it in all its qualities, the fuller our perceptions of it become. 
It is natural for some minds to note one quality of an object 
keenly and to slight the other qualities; some persons are more 
alive to form, others to color, and others to still other qualities ; 
and because of these innate tendencies in various minds we get 
such different results in their reports concerning objects. This 
is the principle that is at the bottom of so many conflicting 
statements and half truths about things in life. Each person 
reports things from his point of view, colored by his own par- 
ticular way of looking at them; if he have an eye for color and 
not for form, we get perhaps the truth so far as the color of an 
object is concerned, but often a very distorted and untruthful 
representation so far as its form goes, and vice versa. If six per- 
sons witness an accident in the street, we shall get six very dif- 



Chap. XVIII] A TALK ON PSYCHOLOGY 245 

ferent reports of the occurrence, all representing certain sides of 
the truth, but no one of them representing the whole truth, 
because no one saw the whole truth, but only what appealed most 
to his powers of observation. The real education of our minds, 
then, consists in training the senses to be keenly alive to all the 
qualities of objects of study; we need to look all around them, 
to apprehend them in all their relations; and in proportion to the 
honesty of our observation, and to our discriminating attention, 
will we be rewarded with a truthful knowledge concerning them. 

Our experience in reality is made up of what we consent to 
give heed to. It is the interest with which we regard things 
that makes them enter into our experience and become a part of 
ourselves. If they slide off, like water off a duck's back, it is 
for us almost as though they had never been. This is a truth that 
works for good as well as for ill. By inattention to the every- 
day beauty of the world around us, and inattention to the moral 
beauty as well, we render ourselves blind to it; it is as though 
it did not exist, and yet we are aware of a hundred and one less 
ennobling things which occupy the center of our consciousness 
because of the keen attention we give to them. On the other 
hand, because of our ability, to select what things we shall allow 
to occupy the center of our consciousness, we are enabled to 
crowd aside to a great degree unworthy objects of attention, 
moral ugliness, unwholesome stimuli, perverted thoughts, and 
the like. The old saying, that as one makes his bed so he lies 
in it, has its counterpart in the literal truth that by the way of 
attending to things and the kinds of things attended to, each 
chooses for himself what kind of a world he will live in. 

Investigations show that when the cortex of the brain is 
electrically excited, respiration and circulation are quickened, 
the blood pressure rises, as a rule, all over the body; the instru- 
ment called the sphygmograph shows decided pulse variations 
during intellectual and emotional activity and repose. The 
blood supply to the extremities is diminished during intellectual 
activity; cold hands and feet are the result. When less blood 
goes to the arms, more goes to the head. Scientists have proven 
by exquisitely adjusted apparatus applied to patients that so 
slight a thing as the entrance of a professor in the room has 



246 NURSING THE INSANE [Chap. XVIII 

appreciably altered the blood supply, that the effort to think, 
that even being spoken to, are all registered by means of me- 
chanical contrivances, all of which goes to prove that there is 
nothing that we see or hear or feel, or experience in any way, 
intellectually or emotionally, but affects our bodies correspond- 
ingly, and accordingly our minds, since bodies and minds in 
living human beings cannot be rightly regarded except as parts 
of one whole. We are prone to lose sight of this fact and to 
make light of the impressions that are coming to us as healthy 
individuals, as of little or no importance, or only of passing 
moment, but it is literally true that we are the sum of all that 
we experience, and that our surroundings modify our physical 
and intellectual lives at every turn, leave their emotional imprint, 
determine our various reactions, and so fashion our characters. 
If this be true of the healthy body, it is much more so of the 
diseased one, especially true of patients with nervous and men- 
tal disorders, with their exaggerated sensibility. The practical 
point we need to consider in contemplating this truth is in re- 
ducing to a minimum all the unfavorable influences or stimuli, 
and in increasing to a judicious degree the favorable ones. 
Noise, contention, disappointments, the irritating effects of too 
much light, the presence of antagonistic personalities, the ap- 
plication of injurious physical or mental stimuli of whatever 
kind, must all be avoided in our care of nervous and mental 
invalids. Excited cases need a lessening of all stimuli, even 
ordinarily favorable ones; depressed ones need a judicious 
application of those which will arouse the system to wholesome 
and normal reactions. 

We commonly speak of various faculties of the mind, such as 
perceiving, reasoning, judging; but the more modern way of 
looking at these things is to regard all these different mani- 
festations of intelligence (knowing) as so many different ways 
in which ideas combine with one another; in other words, they 
are regarded as images of various sensations associated together. 
We arrive at the knowledge of the workings of mind largely 
by looking into our own minds and thinking about what we find 
there. This looking within is called introspection. The things 
we think of are cogitations, and the knowledge thus derived is 



Chap. XVIII] A TALK ON PSYCHOLOGY 247 

cognition. What happens when thinking is going on in a mind ? 
Several things happen. The thought tends to become a part 
of the personal consciousness ; the thought is always changing, 
it is continuous, it always appears to deal with objects independ- 
ent of itself, and it is interested in some parts of these objects 
to the exclusion of others, so that it is choosing among them all 
the while. Since thought is in constant change, our point of 
view is constantly shifting ; we see things in new relations ; we 
see similar things differently under different conditions ; we can 
never have the same state of mind twice ; all preceding sensa- 
tions, thoughts, and experiences modify succeeding ones; we 
are remolded anew at every moment; and what we feel and think 
now, at this moment, is a product of all that we have thought 
and felt before. We look at the face of a friend to-day; it is 
a different face than we ever saw before. The impression we 
get is a complex one, not dependent alone upon what we actually 
see at the moment, but upon all that we have seen before, all 
that we have felt before, and all that we are feeling now, plus 
all the varied modifications that have taken place in the face 
itself by reason of our friend's varied experiences — these modi- 
fications are all fused into a complex feeling that we lightly 
speak of as looking at a friend's face. The friend is changing 
and we are changing ; of necessity it follows that we can never 
see his face twice alike. 

Although our state of mind or our consciousness is changing 
all the time and we are seeing things in new lights and in differ- 
ent relations, so that to an attentive observer the same objects 
never appear twice the same, still within each personal conscious- 
ness the stream of thought is sensibly continuous, and if any 
temporary interruptions occur in it, that is, if the person becomes 
momentarily unconscious, either by fainting away, by taking an 
anesthetic, or in sleep, when the gap in time is bridged over 
again, the person is aware that there has been a gap; he comes to 
himself, we say, becomes conscious of his own personality; he 
awakes, and remembers, and understands. This part of us that 
is conscious of the fact that all the experiences that have come 
to us belong together and are inwardly connected, forming a 
common whole, is what we call the I, the ego. 



248 NURSING THE INSANE [Chap. XVIII 

The whole universe is divided into two portions by each 
creature — the " me," and the "not-me." All that comprises the 
me, and that is included in mine, is of paramount importance to 
the individual. No creature, however humble, but exalts the me, 
is interested chiefly in the me, in preserving, expressing, and re- 
producing the me; and all the remainder of the universe is 
grouped in one foreign mass as something outside of the me. It 
is right that this should be so; it is provided for in the inherent 
nature of things; only so could life be successfully carried on in 
a world teeming with so many different species, and so many 
different individuals, struggling for existence. 

All that pertains to a man is broadly included in his me, in 
his self — not only his body and his mental powers, but his be- 
longings, his home, his family, his ancestors, his reputation, his 
work, and the like. These things constitute a man's Self in the 
widest sense. This Self may be subdivided into separate selves 
— the material self, the social self, the spiritual self, and the pure 
Ego. The feelings and emotions that grow out of these selves 
are called self-feelings, and the actions prompted by these self- 
feelings are self-seeking and self-preservation. Out of the condi- 
tions and needs of the Material Self grow the care and preser- 
vation of the body, the custom of acquiring things, a home, 
property, belongings; one's family is also grouped under this 
head, as we consider the different members as bone of our bone 
and flesh of our flesh; what concerns them, if we have the normal 
feelings toward them, concerning us only a little less intimately. 
The Social Self has to do with man's relations to his associates. 
Man is a gregarious animal. He likes to flock with his kind. He 
likes to be noticed and favorably noticed. He lives up, or down, 
in a surprising degree, to what his associates think of him; his 
respect for self naturally increases or diminishes according to 
the respect in which he is held in the community. If the feelings 
which make up this social self are exaggerated one way or the 
other, we get marked manifestations as a result. The person 
may have an overweening sensitiveness as to what others think 
of him, and so be swayed far away from his own center, or he 
may have an alteration of the social instincts and become a 
recluse, a misanthrope, or even a man hater. The Spiritual 



Chap. XVIII] A TALK ON PSYCHOLOGY 249 

Self has to do with a man's inner or subjective being, his mental 
faculties or disposition. This is the most intimate part of our- 
selves; it is nearer than our bodies, for it is that inner existence 
of which we are conscious when we sense, perceive, weigh, and 
decide things and feel that it is the real self within us that is 
doing it, the Self of selves. It is the part in us that presides 
over what we are experiencing, and decides what our acts shall 
be. When this part of us becomes so altered that our subjective 
life undergoes a radical change, we are said to be alienated 
from ourselves, or insane. Over all these selves, even the Self of 
selves that perceives and decides things, is a consciousness of 
self, a feeling of personal identity — a feeling that the real I 
exists whether the body is acting or refraining from acting, and 
this permanent feeling of being one's self constitutes the pure 
Ego. 

Self-feelings arise out of this complex thing we call Self. They 
are of two kinds, self-complacency and self-dissatisfaction. Self- 
complacency seems made up of self-esteem, pride, vanity, and 
kindred things, and self-dissatisfaction of humility, modesty, 
diffidence, shame, contrition, and the like. These two oppo- 
site feelings are common to all of us; sometimes one predomi- 
nates, sometimes the other. They are dependent upon a com- 
plexity of things, and are subject to great variations according 
as we meet with success or failure in our undertakings, and as 
our bodies are working healthily and harmoniously; and again 
these opposite feelings play hide and seek with each other, 
without our being able to say just why first one, then the other, 
predominates. Each of these states has its characteristic bodily 
expression. In self-complacency the extensor muscles are in 
action, the eyes are bright, the nostrils dilate, the mouth is 
wreathed in a complacent smile, the carriage of head and body 
is commanding, the gait rolling and elastic, and the voice full 
and vigorous. In the opposite mood, when it is extreme, the 
flexor muscles are innervated, the figure is drooping, the head is 
bowed, the eyes downcast and dull, the voice low, the move- 
ments languid, and the whole tendency is to cringe and slink 
away from notice. Varying degrees of these opposite states of 
feeling may be observed any day in your acquaintances, or in 



250 NURSING THE INSANE [Chap. XVIII 

chance passers-by, and the more extreme expressions of these 
self -feelings are before you continually on the wards. 

The things that the Self has to accomplish are self-seeking and 
self-preservation. Self-seeking may be bodily, social, or spiritual 
self-seeking. Under bodily self-seeking come eating, drinking, 
defense, acquisition, homemaking, and the countless things 
that contribute to our material welfare. Social self-seeking 
is carried on through amativeness, friendliness, a desire to 
please, love of fame, of influence, etc. Spiritual self-seeking 
includes every impulse toward psychic progress, whether intel- 
lectual, moral, or spiritual in the more narrow sense of the term. 
It is the reaching out of the creature for all that will elevate and 
redeem the inward nature. 

All these selves are constantly engaged in a sort of rivalry or 
conflict, and sometimes one has the mastery, sometimes the 
other. In some persons we get but faint glimpses of anything 
but the material self, such a hold has the material life on their 
aims and thoughts and activities; in others the social side of 
life is the greatest thing to be desired, and these count all else 
well lost if they compass their heart's desires in the social realm; 
while the seeker of his truest and deepest self counts the world 
which is lost to him as of little account if he possess his own soul. 
The well-rounded individual knows himself, knows that none of 
these selves can be ignored; that each side of his nature is given 
him for a wise purpose to help him fulfill his destiny, and to 
bear the proper relation to other lives that touch his life; but 
each person needs to examine himself, determine which self- 
seeking he is to pursue with the greatest earnestness, which aims 
seem to him the most to be desired ; then, steadily pushing on in 
that direction, make all other efforts subordinate to the chosen 
ends. This is what makes of a life a success. It may not be a 
success in the opinion of others with different aims; but, how- 
ever low the standard, if the individual sets forth to himself 
clearly which self-seeking he most desires to achieve, and in the 
end achieves it, his life is a success in that direction, so far as his 
point of view is concerned. If his aims have been what a more 
spiritual-minded person would call low, if he has eaten of the fat 
of the land, if he has lived in the life of the senses, if he has been 



Chap. XVIII] A TALK ON PSYCHOLOGY 251 

concerned chiefly in acquiring treasures that moth and rust can 
corrupt and thieves break through and steal, if he has been pos- 
sessed with the "mania of owning things," if he has been blind 
to the physical beauty all about him and to the moral beauty 
that is exemplified in humble lives that he scarcely deigns to 
notice, if he has never known the luxury of self-sacrifice, he has 
nevertheless achieved his success; for, to him, the material self 
was the real one, its triumphs were his only triumphs, its failures 
his only failures; he reckons it no shame to have failed in the 
development of the higher and better selves. 

Between the extremes of those who make material self-seeking 
and spiritual self-seeking their aim there are all grades, and in 
individual natures these various selves are often contending for 
the supremacy, and so we get all the variations, from the pro- 
nounced egoist to the most visionary altruist; we get the miser 
on the one hand and the socialist on the other; the fighter, and 
the one who runs away to fight again (or run) another day; the 
athlete and the bookworm; the globe-trotter and the hermit; 
the epicurean and the stoic; the mystic and the scientist; the 
practical man and the poet; the carnally minded and the spiritu- 
ally minded; in short, all of the sharp contrasts as well as their 
intermediate grades, according as each individual sets his stand- 
ards for himself and decides which of his selves he will cater to, 
which he shall adopt as expressly his own. 



CHAPTER XIX 

THE POWER OF HABIT 

All living creatures are bundles of habits. Some habits are 
the result of innate tendencies called instincts, and some are 
the result of training and education. Even the elements have 
habits; all matter behaves after its kind; it follows natural laws, 
we say; in other words, it obeys certain innate tendencies. 
These habits are less variable, however, than the habits of ani- 
mate nature. The way that inanimate matter changes is not 
in its individual particles, its atoms, which are not subject to 
change in themselves, but in the rearrangement of its atoms to 
form new compounds, the rearrangement being brought about 
either by outward forces or by inward tension, making of the 
body of atoms a different structure. For example, a bar of 
iron is rendered magnetic by being brought close to a natural 
magnet. Its appearance is not thereby changed ; the change 
is wrought inwardly in the molecules, rendering it attractive to 
iron filings. 

Our clothing acquires habits, takes on the creases that are 
caused by our forms and movements; old locks work easier than 
new ones; a paper once folded tends to fall into the same creases 
again. 

In a general way, animals of a given species have very similar, 
almost identical habits, which are the result of their inborn tend- 
encies and handed down from generation to generation ; but 
some of these habits undergo modifications to suit varying con- 
ditions. 

We say of anything that is capable of gradually yielding to an 
influence, so that it in time can be modified, that it has plas- 
ticity. If anything yields too readily to an influence, we speak 
of it as being unstable; if it undergoes change very slowly, 

252 



Chap. XIX] THE POWER OF HABIT 253 

tenaciously holding to its original structure and habits, we speak 
of it as stable. And between the extremes there are all grada- 
tions of plasticity, and each modification, the effect of outside 
influence, results in a new set of habits. 

Nervous tissue is especially susceptible to influence; in other 
words, has great plasticity; consequently living beings are 
capable of being trained to new and still newer sets of habits by 
virtue of their nervous systems. Just as water hollows for itself 
a channel which deepens and widens with time, so impressions 
made upon our nervous systems wear paths that become more and 
more easily followed as time goes on. And this is true of other 
bodily structures also ; an ankle that has been sprained once 
yields more readily to succeeding strains ; a joint that has been 
dislocated easily succumbs to a lesser force in the future; a 
mucous membrane once the seat of inflammatory and catarrhal 
changes is rendered more susceptible thereafter, so that we ac- 
quire, as we say, the habit of taking cold. This habit tendency 
is seen in many functional nervous conditions; neuralgias, for 
example, once set going, have a tendency to continue ; the pain 
habit is established, and the patient becomes a victim of the 
habits of his nerves. 

Brain and cord can only receive impressions through the 
blood and through sensory nerve roots. These two forces deepen 
old paths or make new ones, and on them depends the plasticity 
of the brain. 

We learn from studying habits that their practice simplifies 
movements, making them more accurate, and diminishing 
fatigue; that the more often we practice a habit, the less con- 
scious attention we give to it, doing it automatically. 

Professor James points out the beneficent as well as the evil 
effects of habits, in that the acquiring of them enables us to 
accomplish most of the necessary acts of daily life with more or 
less automatism, leaving our higher centers free to work on higher 
things. He reminds us that habit keeps each one of us fighting 
out the battle of life upon the lines our inheritance and early 
choice set for us, and he says that on the whole it is well for the 
world that in most of us, by the age of thirty, the character has 
set like plaster, and will never soften again. 



254 NURSING THE INSANE [Chap. XIX 

It is generally conceded that the ages from childhood to twenty 
are the most important ones for fixing personal habits, such as 
those of speaking, gesture, motion, and address, while from 
twenty to thirty is the critical one for the formation of intel- 
lectual and professional habits. 

Psychology teaches us the importance of making automatic 
and habitual, before the age of twenty, if possible, as many useful 
actions as we can, at the same time that we guard against grow- 
ing into undesirable habits of life and thought. 

None of us wishes to be at the mercy of the hundred and one 
acts of our daily life, having to decide, for example, whether we 
shall get up at this time or that time, or begin work at such a 
time. We need to make these things a matter of daily routine, 
so that we regularly and systematically engage in them without 
thinking, and without decision, thus setting the higher powers 
of mind free to attend to their particular work. 

If we wish to acquire a new habit or abandon an old one, we 
must take care to start on the new course with as strong and 
decided a beginning as possible. In order to do this we must 
summon all the help we can to the desired end; make clear to 
ourselves the right motives; provide against loopholes for our- 
selves or others who will drag us back to the old habit, or pre- 
vent us from starting the new one, as the case may be; do every- 
thing to encourage the new way; make engagements that will 
prevent us from yielding to the old habit; take public pledges 
if necessary — reenforce our resolutions with every aid we can, 
and thus we start on the new course with so many advantages 
and aids toward making a success of it, and acquire such mo- 
mentum in the new path that the temptation to yield does not 
come so soon; and each day that we persist in the new course 
we get stronger and stronger to withstand the temptation to fall 
back into the old one again. 

Exceptions must not be allowed to occur till the new habit is 
securely rooted. We cannot, like Rip Van Winkle, say "just 
this once," and expect to get back easily into the new way. If 
we drop a ball of yarn, it unwinds, and just to the extent that it 
does must we wind it up, and so lose the time we would have had 
to make new windings. Each time we fall back into undesir- 



Chap. XIX] THE POWER OF HABIT 255 

able ways we lose ground, time, and strength, instead of having 
these to expend upon advancement toward the goal we seek. 
Each time we resist a habit that we wish to overcome, or 
strengthen one we wish to acquire, we accumulate help for 
future success in the desired direction. 

Another maxim is to seize the very first possible opportunity 
to act on every resolution you make, and on every emotional 
prompting you may experience in the new direction. It is put- 
ting resolutions into action that starts up the new paths in the 
brain. Prompt and definite action is what makes a life effectual. 
Dreaming and resolving, floundering about in a sea of sensibil- 
ity, of emotion, never bringing about concrete deeds — these 
traits characterize the sentimentalist. There is no objection 
to the dreaming, provided it be followed up with doing. 

One of the most helpful suggestions to this end which Pro- 
fessor James offers is the rule: "Keep the faculty of effort alive 
in you by a little gratuitous exercise every day"; in other 
words, by self-denial in some little unnecessary points, merely 
for the sake of self -discipline. Do something daily just because 
you would rather not do it, and so acquire the habit of conquer- 
ing your desires in minor matters ; thus you will be preparing 
yourself to stand greater tests when they come to you. 

These suggestions are offered here not only as an aid to the 
nurse in acquiring self-mastery and self-control, but also with 
the hope that the truths contained in them will aid her in at- 
tempts to help her patients to break up old and undesirable 
habits, and to form new, desirable ones. 



CHAPTER XX 

AIDS TO PSYCHIC TREATMENT 

It has been emphasized in preceding chapters that when the 
physical needs of the patients are all attended to, there yet 
remain other and higher ones, and that the nurse's work is only 
half done if these latter needs are ignored. 

Each human being is made up of two parts, the physical 
and the psychic, body and mind. One is as important as the 
other; they are closely related and interdependent. One can- 
not be ignored or wrongly treated without the other suffering. 
One is worthy of as much respect and attention as the other. 
The good we do in the world is in proportion to the harmonious 
working together of the physical and the psychic powers with 
which we are endowed. 

Physical disorders need hygienic, medicinal, and palliative 
remedies; these various means employed are grouped under the 
one head of therapeutics. Psychic disorders require psychic 
treatment, and means employed to this end constitute psycho- 
therapy. 

It is mostly for convenience of statement that we speak of 
bodily and psychic conditions separately; as has been said, in 
each human being they are so intimately blended that what 
affects one influences the other; and the most effectual care of 
our patients will result from keeping in view the curious inter- 
relation between our bodily functions and our immaterial selves. 

It has been said that " a normal degree of want of balance gives 
personality. Its accentuation gives rise to originality and odd- 
ness; its exaggeration becomes actual disease." We have to do 
with an exaggerated want of balance in our patients, but in our- 
selves and in those with whom we are thrown in daily contact 
in any walk in life, there are varying degrees of want of balance 

256 



Chap. XX] AIDS TO PSYCHIC TREATMENT 257 

in some direction, and it is these varying degrees that give rise 
to the widely differing personalities that we encounter. True 
mental equilibrium, then, is very rare. All of us are mentally 
weak at some point, however intelligent, clever, self-poised, or 
even brilliant we may be. 

Education and the formation of character on a firm basis 
consist in rinding out our weak points and by self-discipline bring- 
ing ourselves to want to do the things we know we ought to do in 
order to round out our characters. 

The first step in helping a patient, both as nurses and physi- 
cians, is to recognize and then admit our kinship to him, in that 
we, like him, have weaknesses and defects that we need constantly 
to strive to eradicate. "No teaching," Fenelon says, "is effec- 
tual without example ; no authority is endurable save in so far 
as it is softened by example.' ' To put this truth into practice in 
our daily intercourse with patients places us in the best position 
really to help them. 

Helping the insane is, after all, very simple. It is helping him 
to help himself. It is not to exact blind obedience from him, 
but to persuade and influence him so that he will want to do the 
things he ought to do, will want to think the way he should, 
and will want to feel the way he used to feel. Therein the 
patient must minister to himself, but we can aid him in 
self-ministry. 

Cures are brought about in various ways. The most enlight- 
ened physicians are ready to concede that after the mental 
invalid has been put in the best possible condition so far as 
bodily organs and functions are concerned, there is frequently 
needed an added curative power addressed chiefly to the 
psychic side. It may be through an emotion, by distraction, or 
by persuasion — whatever the stimulus used, we often see that 
these intangible means are helpful in brushing from the con- 
sciousness parasitic ideas that have been hindering the patient's 
cure. Our aim, then, is to help to dislodge injurious thoughts 
on which the patients focus, by substituting fresh interests to 
occupy the center of consciousness, so that these will in time 
crowd the false and morbid ideas to the outer rim, until they 
finally disappear. A strong aid to this end is to encourage the 



258 NURSING THE INSANE [Chap. XX 

patient to help others, his fellow-patients and the nurses. Es- 
pecially is it good for him to feel that as you are trying to help 
him, so he can help you. To be interested in something beyond 
self, that is the secret of happiness. By giving to others we 
escape from the prison of selfhood; we become emancipated. 

"Doctor, I do be thinkin' all the time will I go to heaven 
when I die; do you think that way, Doctor ?" This is the 
daily and hourly burden of one poor sufferer who graphically 
describes how everything she tries to do from morning till night 
and far into the night is permeated by this concern for self; 
it occupies the center of her consciousness; she is forced to lose 
the whole beautiful world about her in this fruitless query as to 
whether she will save her own soul; and there is no more miser- 
able being in the institution. Though she were given the free- 
dom of the world, she cannot escape from the prison of Self. 
This extreme case only differs in degree from other cases of 
morbid self-feeling in both the sane and the insane. 

In your efforts to help a given patient, begin by finding all the 
encouraging things you can in his make-up. Emphasize these 
in your own mind and in your intercourse with him ; this em- 
phasis encourages optimism, and that is the best attitude toward 
any reform. Then, to know that he is not alone in his weakness 
and battling helps wonderfully. Admit your own shortcomings 
and struggles occasionally to him; take pains to show him some 
instance wherein he has succeeded when you have failed. As a 
rule we are too blind to one another's merits, too conscious of 
their shortcomings ; reverse this attitude, and the results will 
be gratifying to yourself and to those you are striving to help. 

We are all going forward, standing still, or going backward. 
If you will look about you on the wards, you will find that some 
of your patients are going backward, many are standing still, and 
a few are going forward. It will enhance your interest in your 
work if you institute efforts to check the degenerative tendency 
in the first class, to move the stationary ones into the progressive 
group, and to aid the ones who are progressing to still more rapid 
advancement. 

We need not be ashamed of physical blemishes ; they are often 
incurable, and are, as a rule, things for which we personally are 



Chap. XX] AIDS TO PSYCHIC TREATMENT 259 

not responsible ; but to a great extent we fashion our own men- 
tality, and our mental blemishes are things we should rid our- 
selves of, both for our own sakes and for those upon whom, by 
example, we have such an influence, because of daily association 
with them. Mentality is not a fixed thing, as we learned in the 
talk on psychology ; it is constantly changing; we are capable 
of improvement, of change, of growth, in proportion as we edu- 
cate our reason and cultivate self -discipline. Our highest duty 
both to ourselves and to others is to transform undesirable 
mentality into a desirable acquired character. 

We are a bundle of cells, and our lives consist in a combina- 
tion of reactions ; innumerable ones take place simultaneously, 
as when we respond to light, noise, odors, heat, cold, voices of 
friends, ideas that generate in our minds, desires that originate 
in our physical or mental needs. Forces other than physical 
that cause us to react are our passions, our religious beliefs, our 
reason. Right conduct consists in proper reactions to the vari- 
ous stimuli that incite us. 

In our bodies, if worn-out particles are not properly removed, 
the useless products undergo decomposition, crowd and clog 
and impoverish the tissues, and disturbances and disorders fol- 
low. It is the same in the mind. Useless and harmful percep- 
tions which get lodged there, instead of being rejected, accu- 
mulate and dominate the consciousness, and interfere with the 
normal course of thought, feeling, and action. 

Conditions of the body give rise to feelings, feelings give rise 
to expressions. Pessimism, for example, often dependent upon 
bodily states, shows in the countenance, in the mental attitude 
to everything, and consequently influences acts. It impairs the 
will and gives rise to a feeling of insufficiency. It induces the 
"I can't" that gets in the way of every action; it causes per- 
sons to spend time and energy lamenting the past, so that 
little force is left to make a more desirable future. It makes 
one magnify every pain, minimize every pleasure. 

The modern conception of the will is to the effect that our acts, 
sane or insane, are largely the consequences of physical condi- 
tions, which, if they were more fully understood, would render it 
possible to foretell the character of the act ; and that the will as a 



260 NUESING THE INSANE [Chap. XX 

specific function does not exist. If this be true, it is of supreme 
importance to keep our physical functions in the best possible 
working order, since there is no telling when undue fatigue, 
impoverished lungs and body cells, clogged intestines, or loss of 
sleep, may influence us in the choice of an act that may alter the 
whole life. To keep the brain cells nourished, since the cortical 
cells generate the impulses that govern us, is of the highest im- 
portance. The functional capacity of the brain is what really 
determines the acts of the individual. If there be undue exci- 
tation, we see marked pressure of activity, an example of which 
can be witnessed in any of our manic patients; if the opposite 
condition obtains, we see the disinclination to thought and 
action so conspicuous in certain depressed cases. 

We can't choose to act one way so long as we prefer to act 
another. Our acts are the outgrowths of our motives every 
time. Whatever we do is in obedience to some sentiment or 
idea, unless it be an instinctive act. Heredity and education 
strengthen our motives one way or the other. We can be slaves 
to good or to bad impulses. 

Throw around a person the right conditions, fortify him by 
desire to choose the right, strengthen him at weak points, 
modify conditions that make the strain too great, keep his 
bodily health and strength up to par by food, exercise, and 
sleep, and then know that his actual choice depends upon 
which is stronger, the cumulative power of these right con- 
ditions, or the temptation ; and upon which is stronger de- 
pends his success or failure in coping with the situation. It 
is all very well to tell a person to use his will, but do all you can 
to bolster up his will, and don't put it to too strong a test. The 
old story of Ulysses and the sirens shows the wisdom of fortify- 
ing one's self in advance so that success, even against odds, is 
attained. 

People are what they are because at the time they must be. Ab- 
sorb this truth; it will make you wisely indulgent. Then set 
about to make them different by helping them to want to be 
different. All weakness, all meanness, all error and sin will thus 
elicit only tolerance and sympathy, and a desire to help to 
better things. But let us remember that because any given 



Chap. XX] AIDS TO PSYCHIC TREATMENT 261 

act is the result of foregoing motives, it does not follow that 
other acts must be identical or similar. We are at liberty to 
change our motives, to create a new way of looking at things, 
to cultivate other ideals and hold to them. 

We need now to consider briefly the vexed question of responsi- 
bility for acts. It is a mistake to suppose that because a patient 
deliberates and finally chooses a wrong course of action he is 
"responsible." The very fact that he deliberates and chooses 
wrongly shows that there is a disturbance in the functioning of 
the higher centers, so that he cannot inhibit wrong thoughts and 
later, wrong acts. 

In judging of the responsibility of a person with reference to 
a given act, many factors have to be taken into consideration — 
the hereditary influence, his environment, his personal character- 
istics and predilections, his condition at the time of the act, 
and the immediate agents which provoked it. 

Our attitude toward the misdeeds of patients will distinctly 
change as we get more enlightened views concerning them. 
These being obtained, we will never resort to the absurd "law 
of retaliation." Our business is to prevent the recurrence of 
misdeeds by studying into the conditions and influences that 
lead up to them. We must then seek to change unfavorable 
circumstances, that can be changed, and to bring about the 
right mental attitude toward those that must be endured. 
Brutal repression and injudicious indulgence are alike harmful 
in dealing with patients. First understand the causes of their 
many acts, then you can forgive. But do not stop with merely 
forgiving — that would be weak. Set about to help the delin- 
quent to acquire a desire to do better, then the need to forgive 
will not again arise, or at least not so frequently. We must 
not expect miracles. All these steps must be evolutionary. 

Modern psychologists believe, not that thought, feelings, and 
volition exist as separate entities, and that disorders in the 
one field are entirely distinct from disorders in the other, but 
that the cerebral functions are composite, that they work to- 
gether, and that disturbances in one function must of necessity 
create greater or less disturbances in others. 

As we said before, acts are regarded as the result of functional 



262 NURSING THE INSANE [Chap. XX 

activity of the nervous system. "Men's characters are deter- 
mined," it has been said, "by their visceral structure." This 
conception of ourselves ought to tend to do away with the old 
notion of regarding the body and its functions in a degrading 
light, and as part of our baser natures ; it ought rather to make 
one feel that each "part and tag of me is a miracle," and that 
body helps soul on its way no less than soul helps body. 

To regard conscience as that still small voice within that 
tells us what is the wrong course and what is right, is now con- 
sidered antiquated in the light of modern research. Our so- 
called consciences are constantly changing and are affected by 
our bodily states to a surprising degree, and are at the mercy 
of them to a degree that forces upon us the conviction that it 
behooves us to dignify and safeguard and keep in the best of 
conditions the life of the body, if we wish to further the best 
interests of all that we include when we speak of the life of the 
soul. 



CHAPTER XXI 

APPLIED PSYCHOLOGY 

Who is there who has not at least one besetting sin ? It may- 
be lack of punctuality, it may be sharpness of speech, it may 
be garrulity, or a prying curiosity into the concerns of others, 
it may be slackness about dress or person or belongings, or f orget- 
fulness — whatever it is, it makes us less efficient than we would 
be if we were to overcome it. To set to work to overcome the 
besetting sin which probably each of us knows better than any 
one can tell us, is a duty of to-day. In the matter of lack of 
punctuality — just a few minutes late in getting the wards in 
order, in pinning on apron straps or putting on caps — these 
are trifles, yet physicians come to associate with certain ones the 
condition of being almost but never quite on time. 

It is worse than useless merely to talk about it or about any 
shortcoming. It does no good whatever to harp on besetting 
sins and deplore them over and over. We have enough instances 
on the wards of patients who go about from morning till night 
lamenting because they have not done differently, and never 
getting beyond that. Stop talking about your feelings. After 
once acknowledging to yourself that you have a particular fault 
to correct, cease to dwell upon it, or even to regret it. If you 
find yourself behind time, waste no time nor words in saying 
you are sorry, or even thinking it (unless it is your duty to apolo- 
gize to some one for it), but make a vivid picture in your mind 
of being on time, and keep this picture before you. In other 
words, refuse longer to imagine it possible for you to be any- 
thing but early. In doing this you lessen the old brain impres- 
sion of being late and strengthen a new one of being early, and 
so a real reform is started. 

This same rule applies in dealing with the faults and failings 



264 NURSING THE INSANE [Chap. XXI 

of others — with the patients. To hold up to them their faults 
repeatedly is worse than useless, for in so doing we strengthen 
their impression of these very faults. Encourage, stimulate, 
overlook, but be careful how you constantly emphasize short- 
comings. That is the wrong pattern ; put a newer and better 
one before their eyes. Everything that you can do to make 
them lose sight of their faults will help them to lose the faults 
themselves. 

If we would let all the annoyances of life slide off without 
leaving their imprint, it would be far better for us. Instead of 
that, we are too apt to let them grate and grind, like sand in the 
wheels of a machine, and the friction produced causes wrinkles 
in our faces and wrinkles in our souls. 

It may be you are given to moods. What if you are ? It is 
idle to bewail the fact. Persons who are way down are just as 
often way up. This kind of a see-saw of happiness and unhappi- 
ness is experienced by those whose capacity for getting the most 
out of life is the keenest. This is not saying that we are to 
encourage our moods, but that we are not to resist them. A 
very helpful writer on this subject, Annie Payson Call, whose 
books are so helpful in aiding one to adjust himself to the varied 
relations of life, says one's attitude toward a mood should be 
this : recognize it as a mood and say to it : " Come on. Do 
your worst. I can stand it as long as you can." This is the 
quickest way to make it wear itself out. In other words, treat 
it as you do one who tries to tease you — refuse to be teased, and 
you take the wind out of his sails, as Miss Call says. 

This writer gives some sensible advice in regard to the various 
sources of irritation we encounter in daily life. 

Suppose some one has a disagreeable habit ; you are annoyed 
by it. The annoyance grows on you till this one habit perhaps 
crowds out of your sight every virtue of the individual, and you 
find yourself thinking of him only in relation to this annoyance 
to you. Does your irritation prevent him from pursuing the 
habit? No. Does it do any good to you? It only increases 
your discomfort and prevents you from seeing him except in a 
distorted light. 

The whole complexion of things would be changed for us if 



Chap. XXI] APPLIED PSYCHOLOGY 265 

we would cultivate more tolerance for the frailties of others; as 
we become more tolerant, we get clearer views of excellences, 
and failings drop out of sight. The writer just quoted shows 
how this result may be brought about, by being quite willing 
that persons should persist in annoying habits. For exam- 
ple, say to yourself, "lam quite willing shall make 

that disagreeable noise with her mouth," and, as you hear it, 
say to yourself, "Yes, I am quite willing; do it again, please." 
Persist in this, and it will in time induce a spirit of tolerance that 
will allow you to let the habit pass unnoticed, so far as you are 
concerned. Think what a relief to the nervous system to have 
this source of irritation removed ! We cannot reform the world, 
we would have no time for anything else if we set ourselves 
the task of correcting all the ill-bred habits of persons with 
whom we touch elbows every day. Each individual has to live 
his own life in his own way; if the world is out of joint, we 
need to remember that it is only overwrought persons who feel 
that they are born to set it right. Criticism and preaching do 
but little good; suggestion and kindly persuasion may help, 
but example will do more than anything else to make people 
over into what they ought to be. The sooner we learn this lesson, 
the sooner will a weight be lifted from our own shoulders; the 
sooner we can bring ourselves to take and keep this tolerant 
attitude toward the failings of others, the freer shall we be from 
the annoyances that their failings induce. 

In the matter of abusive patients — we all know how there 
are certain ones who take a malicious delight in using the most 
vile and untruthful language concerning one. They fasten upon 
your peculiarities and exaggerate or willfully misrepresent them; 
make accusations wholly without foundation, and yet, so ingen- 
ious are they that they manage to make them in a plausible way, 
with a show of truth, and you find yourself chagrined, often 
humiliated before the physicians, by these unjust and untruthful 
accusations. You see the patient capable of using reasoning 
power sufficiently to make her accusations telling ones, and this 
makes you think her capable also of refraining from such things, 
so you find welling up in your breast a resentment for her that 
nothing will overcome. You show this resentment in looks and 



266 NURSING THE INSANE [Chap. XXI 

tone, even if you do not mean to do it, and this very resentment 
increases the patient's desire to annoy you still further. 

What you need is sympathy. You need to see things from 
her point of view; to reflect that she is insane; that her judg- 
ment is warped, her ideas distorted, her moral sense blunted; 
and that because for the time she believes you to be all these 
things she says you are, she is to be pitied and excused. Take 
it on a broader than the purely personal plane; reflect how it 
would be if you really were the person she says you are. Would 
you blame her then for saying these things about you? Yet 
that is what you are doing, for she thinks you are what she says 
you are, so, from her point of view, form your judgment of her 
conduct, and you will find yourself losing all resentment toward 
her. One of our best-loved nature writers gives us a hint as to 
how to act toward persons who are trying to annoy us, when he 
speaks of the calmness and dignity of the hen hawk when pursued 
and worried by king birds or crows: "He seldom deigns to 
notice his noisy and furious antagonists, but deliberately wheels 
about in that aerial spiral, and mounts and mounts till his 
pursuers grow dizzy and return to earth again. It is quite 
original, this mode of getting rid of an unworthy opponent, 
rising to heights where the braggart is dazed and bewildered 
and loses his reckoning! I am not sure but it is worthy of 
imitation." 

Instead of taking this lofty view of the situation, one is more 
inclined to think, " She knows better; she has no right to talk 
that way." So you harden your heart against a person who is 
deprived of her reason and her self-control. Try pitying and 
forgiving her on the ground that she is not responsible, and 
see how differently you will feel toward her. She can't see things 
as they are, but should you show resentment to a blind woman ? 
Because she strikes you, are you to hit back? And hit a sick 
woman ? Yet this is just what you are doing when you show 
animosity in look or tone; your nervous system is hitting back 
her nervous system, whereas it is your duty to soothe and help 
to restore her tired nerves, thus aiding her to regain a normal 
way of looking at things. 

Savages slay people with whom they differ. We don't do this 



Chap. XXI] APPLIED PSYCHOLOGY 267 

nowadays. Are we always careful, though, not to harbor hatred 
and revenge in our hearts? Let us guard against showing re- 
sentment in tone or glance, or in using " discipline" toward 
the unruly patient who has offended, or spoken ill of, or ridi- 
culed us. If we do these things, we are killing by inches our 
own tolerance and love for a fellow-being, warping our own na- 
ture, and drying up the milk of human kindness; and the effect 
is not alone upon the patient, who sees that we are failing in a 
spirit of forbearance and forgiveness, but its effect upon our own 
nervous systems is corroding. One's peace of mind and serenity 
of soul are lessened every time one gives way to such a weak- 
ness. Resentment, ridicule, and sarcasm are all corroding in- 
fluences. And has it ever occurred to you how cowardly it 
is to employ these weapons against a defenseless, brain-sick 
patient ? 

" But," you say, " they are not all defenseless; they show a 
surprising shrewdness and malice in their attacks upon us ; 
they take it for granted that, as insane patients, they have the 
liberty to pounce upon our weaknesses and infirmities and hold 
them up to ridicule, and they don't even stop at the truth, but 
invent untruths about us that we cannot endure to hear repeated, 
knowing that the doctors may be influenced by them." The 
truth of these statements cannot be denied. This is one of the 
hardest things you have to bear. The physicians are not insen- 
sible to the trials of your position, and you must not think that 
because they investigate complaints made by malicious patients 
they distrust you. They are only seeking for the truth, and the 
way to get at the truth is to investigate impartially. If you 
are innocent, you should court investigation instead of resenting 
it. It is only just to both you and the patient that investigations 
are made. But how many times is a different view of the case 
taken, a hypersensitive, innocent nurse thinking that the phy- 
sicians distrust her because of necessary investigations. Some 
of you, I am glad to say, are able to look at the matter less sensi- 
tively. Beware, however, that you do not go to the opposite 
extreme, and take it for granted that the physician is always 
ready to believe the nurse; above all, never allow yourselves to 
express or to intimate to a patient that because she is insane 



268 NURSING THE INSANE [Chap. XXI 

the doctors will not credit her statements. Such a thought 
lodged in a patient's mind by an unscrupulous or a thoughtless 
nurse would make a patient distrustful of the entire institution, 
and desperate in her feeling of helplessness, believing herself 
unable to get an unprejudiced hearing. 

Be deliberately kind to the person toward whom you feel 
unfriendly, and you will be surprised how soon you will actually 
begin to feel kindly toward him; laugh with him if possible; 
there is nothing that so quickly establishes a friendly footing 
between persons as being able to have a hearty laugh together. 

If love, hope, joy, trust, self-control, peace, generosity are 
lacking in a nature, and we wish to do good to the one so im- 
poverished, the most effectual way to arouse these qualities is 
to be the embodiment of these ourselves ; let them shine out of 
our lives as a radiance, and they cannot help in time having the 
effect of waking these sleeping qualities in others and so of 
counteracting unworthy emotions that have dominion over them. 

If we entertain thoughts of love, of harmony, of good will 
toward an antagonistic patient or an associate, harboring of 
these feelings must in some measure, often more than we dream, 
arouse the better possibilities within him. 

I have dwelt on these things, many of which are as trite as 
truth itself, not only because they are aids to self-help, but also 
because they contain the same principles of mental hygiene that 
you need to apply in the daily intercourse with your patients 
if you are to nurse their sick minds as well as their sick bodies. 
The old advice to the physician, "heal thyself," is applicable to 
the nurse as well, for the faults and vagaries of the insane are 
only the exaggerated reactions of similar ones that we see about 
us in sane persons, and that, if honest, we must admit we often 
encounter in ourselves. 

You know that there are certain instinctive tendencies in us 
as human beings that bear a large part in our lives, even though 
they are often overlaid and overruled by the higher brain pro- 
cesses — they are the native instincts or impulses, and they give 
rise to certain reactions. In our patients the higher brain 
functions are more or less impaired, so that we have these native 
impulses in the ascendancy; these show our kinship with the 



Chap. XXI] APPLIED PSYCHOLOGY 

lower animals ; while the higher brain processes show wherein 
we surpass the brute creation. 

What are these native instincts that are more or less overlaid 
and controlled by the higher functions, but that become so 
prominent in our patients because of their alienation from the 
normal? Self-preservation and reproduction are the principal 
ones, and out of these grow most of what we call the native 
reactions — fear, love, curiosity, imitation, emulation, ambition, 
pugnacity, pride, ownership, destructiveness, and constructive- 
ness. Perhaps if we realize what these reactions are and rec- 
ognize how innate they are in the lives of all of us, we shall be 
better able to understand some of the manifestations of our 
patients, and, knowing their deep-rootedness, shall perhaps 
grow more charitable when the reactions crop out in exaggerated 
and uncontrolled and perverted ways; not only that, we shall 
also learn how to turn these very instinctive tendencies to good 
results. 

Since in our patients the reason is in part disturbed, it is 
easily seen that the native impulses are the materials with which 
we have most largely to deal. These native impulses, tendencies, 
instincts, are perhaps the ones you will need most to reckon with, 
especially with a certain class of patients. 

You will see many patients in whom the instinct of fear has 
assumed a position of tremendous prominence, crowding aside 
all judgment, coloring all experiences. To allay fears, not by 
argument, but by undeviating kindness, by furnishing things 
to bring out other emotions and so crowd out painful ones, 
is a part of the nurse's duty to such patients. The instinct 
of fear should never be used as a means of discipline or of refor- 
mation. Only an unscrupulous person will try to control pa- 
tients by appealing to their fear of punishment. On the other 
hand, the instinct of love can be utilized at every turn to lead 
the patient into right ways of thinking and acting. Make 
your patients love you by being what you wish to seem to them 
— real helpers and friends. Goodness is more contagious than 
we are wont to realize. 

Curiosity we often see in an exaggerated form in certain 
excited cases, and in some deteriorated ones — the alert curi- 



270 NURSING THE INSANE [Chap. XXI 

osity of the hypomaniacal patient, the peering, open-mouthed 
curiosity of many cases of dementia praecox, and the restless, 
aimless curiosity of senile patients. Sometimes by catering to 
this instinct the attention can be gained and led to something 
more and more helpful, and better behavior can thus often be 
instituted, even though there be little or no hope of improving 
the mentality as a whole. Many depressed patients can be 
roused in this way, after a certain time, and so drawn away 
from their introspection. Find what are the natural interests of 
your patients, and engage their activities in this line ; then lead 
up to better and better things by association and by connecting 
each interest with the one that went before. 

Imitation is an instinct we can enlist at every turn ; of this we 
have spoken elsewhere in emphasizing the value of example over 
precept in dealing with the insane. We see its power in the 
influence of patients on one another, we see its far-reaching power 
in the effect of home life and surroundings and inherited instincts 
in the young everywhere, and the same rules that should govern 
parents and teachers should prevail with us: set a good copy, 
be careful that the pattern is right ; for imitation is one of our 
strongest native reactions. In this connection we have emula- 
tion, which is so closely allied to it and which is responsible for 
so much of the advancement made by individuals and races, 
each wanting to do as well as the other and then a little better, 
and so we come to ambition — all three instincts capable of 
much good if controlled by the higher faculties, but all liable 
to assume undue proportions in a poorly regulated life ; yet the 
very traits that have proved the patient's undoing may in many 
cases be appealed to in order to bring about his restoration to 
mental health. 

Pugnacity is one of the instincts we will find overdeveloped 
in many persons, both sane and insane. It is one of the few 
that we should seldom appeal to, but seek rather to stifle by 
appealing to love instead. We can, however, sometimes enlist 
the patient's pugnacity against some of his own downward 
tendencies, so that this, together with his pride, will help him to 
conquer them. This is legitimate, but try not to call out this 
quality except in such a direction. 



Chap. XXI] APPLIED PSYCHOLOGY 271 

Pride is another instinct that is offensively present in many 
of our patients, but is a trait that we can often enlist in the 
regenerating processes we are trying to bring about. 

Cultivate the instinct of ownership instead of discouraging it. 
This feeling, so ingrained in human nature, leads to order, neat- 
ness, and method. The collecting impulse in the insane is the 
perversion of this instinct, but the efforts of patients at keeping 
together their belongings is the natural expression of this instinct, 
and should be fostered and almost never discouraged. 

Construction and destruction are closely allied. A child will 
tear things to pieces, but if you give him some blocks with which 
to build, the same activity that went to destructiveness will 
be directed to constructiveness, and what is true of children 
in this respect is true to a great extent of many of our patients. 
If you find a patient purloining the towels and bureau covers 
and fashioning various things out of them, do not chide her for 
it; be glad that she has the desire to do things; encourage it 
by providing material with which to work. One of the first 
encouraging signs in many patients is this seizing upon the 
most unpromising materials and making them answer the pur- 
pose of ministering to the constructive instinct. Even greatly 
deteriorated patients would better be employed playing with 
blocks, as children do, or putting puzzle maps together, than in 
tearing things to pieces and giving way to destructive tendencies 
generally, as they will be likely to do if constructive ones are 
not catered to when the time is ripe for it. 

Everything that can increase our knowledge of the patients 
aids us the better to help them. If we see why a thing is so, 
it tends to make it easier for us that it is so, even if the condi- 
tion is a trying one. The deplorable manifestations of many of 
these patients can be good-naturedly endured if they can't be 
cured, but they can often actually be used as stepping-stones to 
betterment. 

The nurse of the insane learns many things about the past 
lives of her patients that should be guarded as sacredly and 
interpreted as charitably as befits one trusted with the care 
of this most unfortunate class of humanity. Patients whose 
lives have been sinful should receive compassion always, never 



272 NURSING THE INSANE [Chap. XXI 

scorn. It is not for us to judge, but to try to understand, 
and pity and restore. All life is a struggle. The history of 
every soul is one of struggling, suffering, sinning, resisting; 
and, in the long run, achieving redemption, or meeting defeat. 
Our own battles, our hard-won successes, our many failures, 
about which none know as we know ourselves, should keep us 
mindful of the battles of those around us; and pity for those 
who fail, where perhaps we have conquered, should be given 
unstintedly. 

As nurses and physicians we come close to the souls of our 
patients ; we see deep into what has been felt and endured ; we 
see how events and conditions have seemed to conspire to make 
defeat inevitable ; the deeper our insight, the wider should grow 
our tolerance, the fuller our sympathy, the more generous our 
help. It is literally true that to know all is to forgive all. 



CHAPTER XXII 

MENTAL HYGIENE 

Mental hygiene is the prevention of mental disease and the 
maintaining of mental health. It must consist of an education 
which takes into consideration, in a given case, peculiarities 
of constitution and temperament, the choice of appropriate 
occupation and pursuits, the avoidance of errors in religious 
teachings, the right attitude toward and the regulation of the 
sexual life, training in right thinking, and encouragement to 
right responses when the various influences call for action. 

It is as important that the nurse of nervous and mental invalids 
learn the principles of mental hygiene as that she understand 
those of physical hygiene. Dr. Adolf Meyer, who, as Director 
of the Pathological Institute of New York State, has done and 
is doing so much to improve the medical work in the State 
hospitals, in one of his lectures to assistant physicians in State 
hospitals, emphasized the fact that "hygiene of the mental 
faculties is as necessary as hygiene of the bowels"; he said that 
we give the truest help to our patients when we aid them to 
get their mental activities adjusted on normal lilies; he holds 
that in order to do this we must appreciate the undercurrents 
in their lives, provide proper food for their normal instincts, 
and so guard against perversions; relieve tension and anxiety; 
soothe excitement; allay fears; and train to good and useful 
habits. 

Mental hygiene, of course, presupposes hygienic bodily con- 
ditions — a sound mind in a sound body. The preliminary 
step, then, in mental hygiene is to secure, later to maintain, 
physical health. 

Good spirits are more dependent upon a body that is working 
in harmony than we are inclined to believe. The contrasting 
states of mind, optimism and pessimism, are largely the result 

t 273 



274 NURSING THE INSANE [Chap. XXII 

of bodily conditions. Fatigue can cause sadness, ideas of nega- 
tion, and of persecution. It can lead its victim to disparage 
everything around him, and can plunge him into the slough of 
pessimism. Even the true lover of his kind, the altruist, whose 
life is spent in beneficent acts, may, under the benumbing in- 
fluence of fatigue, become selfish, and under continuous fatigue, 
prove incapable of reacting against obsessions and impulses 
grown irresistible. Mental states, in their turn, act upon the 
organs and functions of the body. Worry is a most potent 
factor in the causation of many physical disorders; chronic 
diseases are especially aggravated by this destructive process. 
It has long been established as a fact that certain powerful 
emotions, such as fear, or anger, may affect a woman's milk so 
that her child, if nursed soon after, will have convulsions. We 
have in this fact an illustration of the influence of the emotions 
upon the secretions of the body, and consequently upon the 
welfare of the body. We have other familiar illustrations of 
the influence of mental action upon the secretions: sadness 
acts upon the lachrymal glands causing tears; thought of savory 
food produces a flow of saliva, and so on. In these facts we 
get a hint as to the hygiene of our thought life — that since 
thought and emotion really influence the secreting cells of the 
glands, when the result of thought and emotion proves unde- 
sirable and harmful, we should change our thoughts and feelings 
by getting up new interests, thus by substitution dispelling in- 
jurious ones. 

We have already learned that certain changes take place in 
our brain cells during thinking. Thought is the product of brain 
activity. When thought becomes disturbed, when the emotions 
become hypersensitive, some change takes place in the nerve 
cells and their communicating fibers ; upon the condition and 
activity of these nerve cells our activity and consequently our 
lives depend. To think aright is mental health. Ideas are the 
levers that move to action. So long as the thought is right, 
it must follow that successive steps will be right also. 

In acquiring mental discipline and poise, as I have said, the 
avoidance of worry and the cultivation of a hopeful spirit are 
of special importance. Then we must let go of overweening 



Chap. XXII] MENTAL HYGIENE 275 

ambition; conserve the energy so that all efforts count; stop 
unavailing regrets ; cease to dwell upon our own mistakes — 
to cry over spilt milk; and cease to harp on the mistakes of 
others. We must refuse to cross bridges till we come to them; 
try to get a clear view of every situation we are called to meet; 
learn to recognize essentials, to ignore non-essentials ; to over- 
come our own selfishness and obstinacy at every turn ; finally, 
we must school ourselves to control the emotions and passions 
instead of letting them control us. 

Environment has more to do with one's well-being than we 
are wont to realize. There is a marked difference in persons 
in this respect, but all of us are influenced by the rooms in which 
we live — their heterogeneous arrangement, the colors that pre- 
dominate, that harmonize or quarrel with one another, the noise 
or quiet that prevail, the purity or impurity of the air, and the 
sympathy or antagonism of the mental atmosphere. We all 
act and react upon one another, and it is true of every one, even 
of the most self-contained, or of the most callous, that we do 
our best work in what we feel to be a sympathetic environment. 
Persons with an exaggerated sensibility are of course much more 
readily affected by their surroundings than are others, and all 
nervous and mental invalids come under this head. Nurses 
and patients react upon one another to a surprising degree, and 
in numberless ways. What you are is of the utmost importance 
to those around you as well as to yourself: quiet, calmness, 
systematic and well-controlled conduct on your part, are con- 
ducive to the same traits in your patients. A nurse with self- 
control and poise can go into a disturbed ward where everything 
is at sixes and sevens, and succeed in a short time in bringing 
order and quiet out of chaos; while one who is easily flustered, 
is made more so by such a situation, and her well-meant 
efforts only serve to increase the confusion she encounters. 
The one has acquired a self-mastery that the other will need to 
attain before she can hope to have a beneficial effect upon her 
patients. This self-mastery is, as I have stated, primarily de- 
pendent upon the physical condition ; and to keep the body up 
to its best, attention to diet, fresh air, cleanliness, sleep, are of 
prime importance; the avoidance of stimulants, the adherence 



276 NURSING THE INSANE [Chap. XXII 

to good habits, and a clear conscience, are likewise important; 
and a mental activity that makes one alive to everything about 
him, thereby increasing his knowledge and power of applying 
it, goes far toward completing this desirable equipment. 

Let us further consider the emotions, since they are so potent 
in governing our lives. We have already learned that every 
stimulus sets up some kind of a reaction ; that every sensation 
causes some sort of motion in the body (not necessarily appre- 
ciable to us ; it may be motion in the cells that make up the 
various organs); and that every feeling produces a movement. 
Some psychologists, however, say that this is putting the cart 
before the horse, and that emotion follows upon the bodily ex- 
pression of it, at least in the coarser emotions. Professor James 
teaches that we first perceive an exciting fact and that our feeling 
of the bodily changes, resulting from the perception, constitutes 
the emotion. For example, some one strikes me, I strike back, 
and then get angry because I strike; or I see something that 
makes me tremble, and because I tremble, I experience fear. 

Whether we regard emotions as causes of the bodily expres- 
sions of them, or the bodily expressions of them as the cause of 
the various feelings, certain it is that they are closely related, and 
are of tremendous importance in our lives. For our purpose it 
is more profitable to study what bodily expressions accompany 
certain emotional states than to inquire further into which is 
the cause and which the effect. So we will cling to the cus- 
tomary way of speaking of them and say, joy expands, grief con- 
tracts, instead of saying that we expand our muscles and so 
feel joy; contract them, and so experience grief. 

The depressed person sits wrapped round and round in self; 
a barrier seems to shut him off from his fellows. Depressing 
emotions alienate us so that those we love, and the things we 
were once interested in, seem foreign; at first they fail to arouse 
the accustomed interest ; later, they seem to belong to us no 
more; from being in the beginning cold and blase, we come to 
feel a growing sense of inward loneliness and isolation from every- 
thing. 

On the other hand, the tendency of elation is to make one 
interested in others. There seems to be an affinity between 



Chap. XXII] MENTAL HYGIENE 277 

joy and tenderness, and it is a natural step from being happy 
ourselves to trying to make others happy. The joyous emotions 
bring us near to the sensible material world, and we joy in it and 
in our fellow-creatures, and feel at one with so many things that, 
like Stevenson, we come near to being as happy as kings. Other 
things being equal, the more points of contact we have with 
things, the broader the interests, the happier we are, and the 
happier we make others. Sympathy is an evolution of the feel- 
ing of selfishness, although the two seem so widely separated. 
It is a transfer of our own selfish feelings to another personality, 
so that we feel with that other. 

Degeneration of brain cell is believed to result from overstrain 
of many kinds, from worry, long-continued excitement (even of a 
pleasurable kind), from artificial stimuli, from overstudy, and 
from insomnia. All these tend to act unfavorably upon the 
brain cells of healthy, normal persons, and of course their effect 
is even more deleterious upon those who have inherited unstable 
organizations, and upon others whose arterial tissues are in- 
clined to weakness. Youths who break down early from the 
strain of a course of study which has no such effect upon their 
fellow-students, show either hereditary or constitutional weak- 
ness of their nervous systems; precocious children who early 
show such startling promise of mental acuteness, but later dwindle 
into commonplace or even subnormal intellects (thus showing 
their lack of staying power), young persons who under a little 
extra stress and strain succumb to unfavorable conditions, and 
perhaps show early dementia — all belong to this unfortunate 
class. It should be the aim of parents and teachers to safeguard 
such unstable individuals at every turn; to seek in childhood to 
round out their development by making healthy little animals of 
them; to be slow about pushing their education; and to be chary 
of furnishing stimuli to their emotional natures — such stimuli 
as they would get in musical training, novel reading, and in much 
of what goes under the name of religious teaching and influence. 
The crucial times in the lives of these neurotic persons should be 
provided for in advance by so controlling their work and environ- 
ment that these hard places may be passed in safety — the period 
of puberty, the child-bearing periods, the climacteric period. 



278 NUKSING- THE INSANE [Chap. XXII 

In order to lead our patients into self-controlled conduct we 
must furnish them the help that right example gives ; aid them 
in enlarging their interests by good reading, by attention to 
wholesome natural things, and to the right way of looking at the 
daily tasks we and they are called upon to do ; teach them to 
understand the necessary and really ennobling part these play 
in the whole of life, if we but learn to see them as related to the 
whole of life, and not merely as separate items of drudgery. 

It is all very well to have beautiful dreams, high ideals, and 
lofty conceptions, but these alone are of small value. They are 
in mental hygiene of as little value as unused gymnastic appa- 
ratus is in physical hygiene. The apparatus looks well, and 
impresses the casual visitor, but it is decidedly pernicious to the 
one needing exercise of the muscles, if the mere having procured 
it satisfies him and lets him forget that he puts it to no use. We 
must put our thoughts and feelings into acts, if our mental facul- 
ties are to get their needed exercise. We must bring our dreams 
of doing good to the test of actuality. We must make religion 
a religion of deed, not of feeling alone ; must see that pity blos- 
soms into kindly acts ; that charity overlooks unkindness ; that 
our vaunted love of beauty and of harmony is so much a part 
of our daily lives that every one with whom we come in contact 
feels the effects in added beauty and harmony in their own lives; 
in a word, we must transform emotions into actions by relating 
all our fine ideals to matters of everyday living. 

Mental hygiene demands that each one of us, you in your work, 
and I in mine, faces each situation as it presents itself, and acts 
up to our best light as to how to cope with it. It is of small 
profit to think concerning this or that future situation that may 
confront us, "I must do thus and so, because to do otherwise 
would be wrong"; that would be going out in imagination to 
meet a situation which does not exist ; and although we meet 
it and conquer it thus, in the imagination, it does not really 
strengthen us. It is like fighting toy soldiers. What will 
strengthen us, though, is to train ourselves so that we habit- 
ually ask of each question as it confronts us and calls for 
action, "Is it right ? wise ? best ? Is it fair to another ? Just to 
myself to do this, and this?" And having asked and answered, 



Chap. XXII] MENTAL HYGIENE 279 

act according to what really seems right, wise, best, fair, just, 
regardless whether it is easy or difficult of accomplishment. As 
Professor Thorndike says: "Men become efficient and decent 
only by behaving efficiently and decently. To work is the only 
cure for laziness ; to give is the only cure for stinginess ; to tell 
the truth is the only cure for lying." 

In order to control our acts, a foreground of preparation is 
necessary, which consists in controlling the mental states which 
lead up to them. And in order to control the mental states 
leading up to them, we need to arouse the feelings that will lead 
up to the right mental states, and to repress those that would 
lead to undesirable ones. To this end we must put ourselves 
in favorable situations ; we must learn what are the useful in- 
stincts, and give them a chance to be exercised in legitimate 
ways, so that they will become habits ; we must learn to in- 
hibit responses to unworthy instincts ; acquaint ourselves with 
our own weaknesses ; and learn to present clearly to ourselves 
the satisfaction and enduring good that follow worthy acts, 
however (though not necessarily) difficult, and the discomfort 
and far-reaching harm of unworthy ones, however alluring they 
prove. 

One of the most effectual ways to arouse right feelings that 
shall move to right actions is to fasten attention upon something 
of absorbing interest, so that we come to lose sight of the thing 
we know we ought to refrain from doing. It is really very simple, 
after all ; it amounts to substituting one absorbing interest for 
another, until the one comes in time to crowd out the other. 

We may have to help ourselves by avoiding things which 
tempt us too strongly, until we acquire sufficient self-mastery to 
cope with the situation face to face. This may seem cowardly 
in a way, but it is often the safer, if not, indeed, the only way. 
"The better part of valor is discretion." 

Another way to strengthen ourselves in right conduct is to face 
squarely the uncomfortable results that follow yielding to wrong 
acts, and also to look what appears so alluring full in the face, 
and, in sober moments, ask ourselves if a given course is really 
so much to be desired as we have fancied it. By bringing the 
temptation near in thought and under the cold light of reason, 



280 NURSING THE INSANE [Chap. XXII 

at times when we are not blinded by passion, we will often find 
that it was merely distance that lent enchantment, and that, as 
Professor King suggests, the siren has a painted face ; her smile 
is a leer ; her song coarser than we thought. Thus we shall see 
her as she is, and when we so see her she will lose all power to 
charm. Yet, so potent is the force of habit, it will be well to 
keep busy at some absorbing task if circumstances decree that 
we must sail near the siren's rock, lest we forget her leer, forget 
her painted face, and her cruel purpose, when her singing is 
wafted to our ears. 

Mental hygiene demands that we avoid unprofitable looking 
within. If I look myself squarely in the face, see myself as no 
one else can see me — because no one else can know the strange 
mixture of good and bad — what shall it profit me ? Nothing, 
if I let regret and remorse be the final result. They have their 
place as a means to an end, but in themselves are relaxing, ener- 
vating. After this scrutiny of ourselves, we need to right about 
face and march away, not only from wrongdoing, but also from 
the thoughts of wrongdoing; we literally need to put the 
thoughts of our sins from us as far as the East is from the West. 
Further than that, we need to set about the doing of some con- 
crete good. In certain natures the tendency to self-accusation 
and self-depreciation is so great that examination of self is ex- 
ceedingly harmful; it paralyzes, produces inaction, obtuseness, 
and wasting of all the powers. Such persons need to remember 
to be merciful to themselves, though sinners ; to give themselves 
credit for their good deeds as well as for their bad ; they need to 
recall where they have lent a hand here, offered a cup of cold 
water there ; stood up for principle when it would have been far 
easier to have kept silent ; been merciful when others, in efforts 
to be just, have been harsh and unforgiving; and, in this distinct 
effort at seeing the good in themselves, they will come to lose 
sight of the evil, and so be better fitted to overcome evil with 
good. 

We need, then, to be introspective enough to face ourselves 
unflinchingly, face every situation squarely, and determine 
whether we are meeting it honestly; ask ourselves if we are being 
our best selves, giving our best to others; and, after making 



Chap. XXII] MENTAL HYGIENE 281 

sure of these things, we need to forget ourselves in action — in 
doing well the very nearest thing that lies at hand to do. 

It has become a truism that we Americans are too strenuous. 
We keep ourselves busy and excited all the time ; there is undue 
tension in our muscles and in our habits of mind; we forget to 
relax, to take advantage of the power that comes through re- 
pose ; we need to remember to stop and breathe deeply oftener ; 
we need to apply the principle of relaxation to our daily lives, 
instead of merely reading the numerous books that have been 
written on the subject. We need to stay our haste, to make 
delays ; need to reflect that too much eagerness, breathlessness, 
and anxiety are signs of weakness, not of strength; that they 
betoken a lack of inner harmony and ease, and beget feelings of 
unrestfulness in others. 



CHAPTER XXIII 

NORMAL AND ABNORMAL MENTALITY 

Before studying the manifestations of insanity we need to 
take some preliminary steps — to see first how the normal mind 
works, then the abnormal. In 'psychology we study normal 
functions; in psychiatry, deviations of mental functions from 
normal standards. 

In considering any organ of the body we are interested chiefly 
in its function ; in other words, in what it does, in what part it 
plays in the working of the body; for example, the function of 
the heart is to pump blood through the body. In studying the 
processes of intellectual life, we study psychic functions. We 
know these must have some organ. That organ is the brain, or 
to be more specific, the cortical cells in the forebrain or cere- 
brum. It is in these cortical cells that perceptions occur, and 
here that the impulses to voluntary movements originate, and 
also here that memory pictures of other sensations, perceptions, 
and motions are stowed away. 

Sensations are the first steps in brain activity. They arise 
from stimuli coming to us either from external objects, or from 
our own organs, and give rise to perceptions. These perceptions 
take place by means of attention to stimuli, and by means of 
thought, and of memory of previous stimuli. Perceptions are 
accompanied by pleasurable or painful feelings which we call 
emotions. These constitute our mental or psychic activities. 
They are intimately blended, and it is only for convenience of 
study that we speak of them as separate processes. 

It is believed that the higher the race or the individual stands 
mentally, the larger and heavier the forebrain is in proportion 
to its mass ; and the higher a creature is in the animal kingdom, 
the deeper and more complex are the furrows or convolutions on 



Chap. XXIII] NORMAL AND ABNORMAL MENTALITY 283 

the surface of its brain. In a rat or a bat the only furrow is 
around the Sylvian fissure, but as one goes on up the scale, more 
and more convolutions appear. Foxes, dogs, and wolves have 
more than rats and bats, and of course are more intelligent; 
apes have more than foxes and dogs, and men have more than 
apes. Children's brains have a scarcity and shallowness of con- 
volutions, but as intellectual life deepens, the convolutions deepen 
also. Consequently, idiots' brains show a poverty of convolu- 
tions, while the brains of persons noted for mental vigor present 
great variety and depth of these furrows. 

The brain cortex is made up of millions on millions of cells 
embedded in connective tissue rich in blood, and probably all 
communicating with one another by minute fibers. 

By means of the nervous system we are brought into relation 
with the outside world; the brain being the center and the spinal 
cord and nerves working together, we are enabled to receive 
impressions from without, register them, appreciate them, store 
them up for future comparison, respond to them, either volun- 
tarily or involuntarily, and form ideas and opinions, which ideas 
and opinions control our acts, and in time make up our char- 
acters. 

Our interest here is chiefly in the workings of the brain as the 
seat of intelligence. What is it to be intelligent ? It is to see 
and to know what we see; to feel and to know what we feel; to 
hear and to know what we hear; to smell and to know what we 
smell; to taste and to know what we taste. In other words, it 
is to be able to receive impressions through our senses, com- 
pare them with former similar impressions, remember what we 
learned of these former impressions, and in the comparison to 
form correct judgments as to each experience that comes to us. 
Sense impressions vary in kind and intensity ; they are depend- 
ent upon the state of excitability of the organs of sense as well 
as of the centers in the brain, and upon the force of the particular 
stimulus, and also upon the influence of other outside stimuli 
affecting us at the same time. 

We do not get separate single sensations as such. At every 
moment of our lives numerous sensations are coming to us 
through our eyes, and ears, and all the other senses, and these 



284 NURSING THE INSANE [Chap. XXIII 

many sensations coming to us at the same time become mingled, 
and form what are called sensory concepts; these unite and 
become general concepts, and so we have what we call ideas 
of things, and from them we form judgments or come to conclu- 
sions. 

In morbid conditions, instead of sense impressions coming to 
one correctly, certain sense deceptions take place, giving rise in 
turn to false ideas. These sense deceptions are called hallu- 
cinations and illusions ; the false ideas, when they become beliefs, 
are called delusions. In hallucinations, due to some abnormal 
stimulation of the brain cells or sense organs, the patient thinks 
he perceives something which really has no existence; he hears 
a voice when there is no voice ; he sees a person when perhaps he 
is the only one in the room, and in like manner he tastes and 
smells things which have no objective reality, or perhaps he ex- 
periences a feeling of weight upon his muscles, or some sensa- 
tion in his skin which is not caused by anything in contact with 
those parts. In the case of illusions, false impressions result 
from misinterpreting real objects. The patient hears threats 
and curses and agonizing screams in the ordinary sounds about 
him, sees ghosts in the clouds, animals in small, inanimate objects, 
and so on. 

Our ideas are accompanied by certain feelings, or emotions, 
which are pleasurable or otherwise. All the emotions we feel 
at a given time combine to form our mood. Every idea gives 
color to our feelings of one kind or another. If we think of early 
spring, it depends upon what our associations have been with 
it what our feelings shall be. The thought may be associated 
with feelings of hope and promise, of irises and doves and loves, 
of bluebirds and hepaticas, of trout brooks, of planting a gar- 
den, of colds in the head, or house cleaning, and so on. And 
according to the idea do we experience comfort or discomfort, 
pleasure or pain. So we see that an idea which calls up a 
pleasurable emotion in one person may call up just the opposite 
in another, depending upon what his past experiences and asso- 
ciations have been with that particular idea. 

We differ widely in health in regard to our emotional life, and 
when insanity develops, the emotional manifestations are cor- 



Chap. XXIII] NORMAL AND ABNORMAL MENTALITY 285 

respondingly varied. Some cases present dulled, others exag- 
gerated, emotions. Some experience emotions that are incon- 
gruous ; that is, that are at variance with the sense impressions 
they are receiving at the time, showing that they have called up 
ideas from their inner consciousness and are feeling in accord- 
ance with them instead of with what is really happening to them 
from without. In other cases, although the emotions are in 
accordance with the patient's actual sensory impressions, great 
instability is seen, and the person shifts from one emotion to 
another according as the various ideas rapidly present themselves 
to him. 

Our emotions are also influenced by the slowness or the rapid- 
ity with which ideas come to us, and the rate at which they 
come is dependent upon a number of conditions. The shortest 
time in which one idea follows another has been estimated to be 
one eighth of a second. Our attention and our wills can to a 
certain extent only control the procession of ideas through our 
minds, their coming and going for the most part being involun- 
tary. 

When we think quickly, when ideas are grasped easily, and 
remembered readily, we experience a certain ease and pleasure 
in our mental life. When thought is slowed, and something 
seems to hold it back, we experience discomfort. 

The rapidity with which our thoughts work varies greatly in 
different persons, and in the same person at different times. 
Under the influence of fatigue, hunger, insomnia, even a healthy 
brain is embarrassed by slowness and difficulty in thinking. 

Certain disease-conditions show these variations in thought- 
action very conspicuously. For example, insane patients suffer- 
ing from maniacal conditions present lively mental action, ideas 
crowd their minds rapidly, they feel exhilarated by the rapid 
flow of ideas, and a jolly, boisterous mood, subject to sudden 
changes, is common ; while depressed cases, annoyed by diffi- 
culty in thinking, are made still more sad as they realize their 
inability to recall things, and to grasp easily the significance of 
various experiences that present themselves. 

In addition to receiving impressions of things and from these 
impressions forming concepts, ideas, and judgments, ideas may 



NURSING THE INSANE [Chap. XXIII 

come to us in another way ; that is, merely by association. For 
example, if we see a part of anything, we think of its whole; if 
we see an effect, we think of its cause, and vice versa — the one 
suggesting the other; then things are associated by similarity 
and by contrast, by the similarity of sound, etc. This is seen in 
the flight of ideas in manic cases — the sight of different things 
giving rise to a rapid flow of words, as the various associations 
are recognized; the tendency to rhyming in these cases is also 
because of this same association of ideas. 

Under healthful conditions, any concrete idea remains in the 
consciousness but a short time, regardless of efforts of the will 
to hold it, being pushed aside by others and still others that keep 
forming; but under pathological or diseased conditions, where 
the normal association of ideas is hindered, a single concrete 
idea may remain in the consciousness with abnormal intensity 
and duration; this constitutes an imperative idea; and since our 
acts are the result of our ideas, ideas persistently held, however 
erroneous or absurd they may be, come in time to control our 
acts and to make up our characters. Absurd ideas may be 
judged as such by a person in the beginning of mental trouble, 
but as wrong thinking continues, he comes more and more under 
the influence of it, and in time loses his power to interpret things 
correctly. 

All the sensations we experience become a part of ourselves — 
our egos. Each person is made up of a bundle of experiences. 
No two persons can be alike because no two have experienced just 
the same things in just the same way. Each differs from another 
because of different combinations and the different intensity and 
variety of concepts that have combined to form his ego. 

When the brain is properly nourished, and is in good working 
order, then the impressions that come from the world outside 
are received, responded to, and judged in a normal and ade- 
quate way. But when a disease-process is set up, the brain does 
not work naturally; it is set going by stimuli from within as well 
as from without, and the patient finds himself in changed rela- 
tions with the outside world ; his power of seeing clearly and of 
judging wisely is therefore interfered with. 

Insanity has been described as an alteration of the ego. Some- 



Chap. XXIII] NORMAL AND ABNORMAL MENTALITY 287 

thing has happened to the brain to hinder its normal function, 
so the affected person does not respond as before to outside influ- 
ences, and the inner stimuli come more and more to dominate 
him. The perceptions, ideas, feelings, and impulses which arise 
(just as real to him as though they were reactions from external 
sense impressions) are really from excitations arising within. 
So we call him alienated. His inner world is out of harmony 
with the outer world. He is foreign to his normal self because 
his cortical cells fail to act as they normally did. These changed 
relations make him an alien. (You can now see why physicians 
who make a special study of mental diseases are called alienists.) 
When mental disturbances first appear, the patient is often able 
to recognize that his mental processes are not working normally; 
then we say he has insight; but as the condition progresses, and 
the consciousness becomes more disturbed, the patient is unable 
to distinguish between the stimuli which come to him from within 
and without, and so he responds as promptly to one as to the other. 
In auditory hallucinations, for example, he replies to our speech 
to him and to "the voices' ' in his inner consciousness with equal 
promptness. But if the hallucinatory state gets still more pro- 
nounced, the inner stimuli predominate, and he reacts more and 
more to "the voices,'' and grows correspondingly indifferent to 
external impressions. 

Disturbances in the emotional field are usually the first abnormal 
mental symptoms to become apparent. A person may show 
marked emotion without sufficient motive, or may have an ade- 
quate cause for a given emotion, but may respond in such an 
exaggerated way that we call his response abnormal. Or he may 
show perverted emotion — the opposite to what one normally 
experiences under like conditions. 

As we come to study states of exaltation and depression, we see 
that they are only exaggerations of normal psychic experiences. 
We know if we stop to think that there is a very wide range 
to the emotions that normal persons may experience. We feel 
surprise, shame, care, and worry, or we feel pleasure, joy, and 
even wild delight. These extremes may lie within the realm of 
normal experience, or they may escape these bounds and become 
pathological conditions. 



288 NURSING THE INSANE [Chap. XXIII 

The expression of the normal emotions and of pathological 
ones is the same, differing only in degree. Painful thoughts 
and feelings show themselves in a normally depressed person 
very similarly to the way they do in the pathologically depressed 
one; but aside from the degree of expression there is another 
very important thing to be considered. The normally depressed 
person feels pain and sadness from adequate cause ; the emotions 
are the result of conditions that naturally cause pain and sad- 
ness, while the pathologically depressed person suffers from 
insufficient external cause, consequently as a result of inner 
processes. 

Or, if an adequate cause started the depression, the mani- 
festations may reach an abnormal degree; we so regard them 
when the person magnifies the causes, and when he is unable to 
let the healing forces of nature, hope, and time do their work, 
as they ordinarily do in normal persons overtaken by depressing 
factors. When introspection, self-accusation, and lamentations 
go from the normal into the realm of the morbid, we call the 
person insane in the emotional field. 

Likewise in states of exaltation. We feel exhilarated from a 
brisk walk on a clear, cold night; the exhilaration shows itself in 
face, voice, gesture, almost like a mild intoxication; or we show 
gladness and even unbounded joy at some rare good news; still 
there are limits to the bounds of our extravagant expressions. 
But the abnormal person cannot control his exhilaration; he 
passes beyond the limits of propriety and decency; again we call 
him insane. 

Children have not learned to govern their emotions. A child, 
in going out into the fresh air and sunlight, dances and skips 
with joy, thus reacting to these external stimuli regardless of the 
presence of his slow, sober-going elders. We, under the same 
conditions, feeling perhaps the exhilaration, react by a statement 
as to its being a glorious day, or we fill our lungs a little deeper, 
and perhaps walk with a sprightlier step ; but we have become so 
hemmed about with custom, so used to repression, that we per- 
mit ourselves no other expression of the pleasure we feel. 

The insane person is like the child. Impressions that come 
to him from within or without meet with uncontrollable mani- 



Chap. XXIII] NORMAL AND ABNORMAL MENTALITY 289 

festation. Hence the extravagance and often incongruity of 
his actions, especially in certain types of insanity. 

The genius, too, is like the child in that his responses are keen ; 
he feels things to a degree that less sensitively organized and 
better-controlled persons (that is, persons able to repress their 
feelings) do not. He sees things, too, in new relations. He 
gets called eccentric and sometimes foolish because he does not 
preserve the manner of mediocrity; but it is just because he is 
gifted with a vision withheld from ordinary mortals that he is 
enabled to bless the slow-going "normal" individual with the 
materialized vision which the normal man, though having eyes, 
sees not until it is materialized. So through geniuses we get the 
world's best paintings and sculpture, poems, music, inventions, 
discoveries. 

There are other types near to geniuses, but lacking the divine 
fire, the individuals of which, like geniuses, have an unusual 
association of ideas — things strike them in original ways, they 
see them in the light that never was on land or sea, and often 
because of their ability to see commonplace things in an unusual 
light, they develop ideas that are really of value. Such persons 
are prone to dream of revolutionizing the race, but lack the abil- 
ity to do as well as to dream ; they are unbalanced, one-sided, 
and their visions are likely to come to naught just because of 
this want of balance ; some others, of a similar make-up, but 
with more executive ability, found sects, start revolutions, and 
swell the ranks of fanatical reformers. The tendency of these 
eccentric persons to hold to their ideas, however unusual and 
absurd, till everything is colored and distorted by them, shows 
them to belong to the type from which we get our so-called 
cases of paranoia. 

Dreams furnish a means for helping us to understand the 
abnormal working of the mind in insanity, because in both 
these conditions ideas and sense impressions occur mostly 
from inner excitation, dependent upon some changes in the 
blood, instead of from external influences. Therefore the ideas 
that arise do not correspond to reality; yet, since the power to 
judge correctly is in abeyance, the various ideas come and assert 
themselves, however incongruous they may be; and because 



290 NUESING THE INSANE [Chap. XXIII 

of the disturbance in the association of ideas, ideas elbow each 
other in a helter-skelter way, without the dreamer, or the in- 
sane person, as the case may be, being able to detect the mental 
disorder. 

We know how in dreams the most improbable and contra- 
dictory things happen without causing surprise, and it is only 
when we start to relate the dream that we note certain dis- 
crepancies and incongruities. This may help us to understand 
the usual inability of the insane person to recognize the absurdity 
of his false beliefs, or to be reasoned out of them. But, as I 
have said, some insane patients have insight. Just as in our 
dreams we occasionally note an improbability and think, " This 
must be a dream," but go on dreaming, so the insane may have 
fleeting insight, or more permanent insight, as the case may be; 
again they are sometimes able to recognize their hallucinations 
and delusions as such, and anon mistake the inner for the outer 
stimuli. In dreams our powers of deduction and judgment 
are temporarily in abeyance, while in the insane they are dis- 
turbed to a more marked and a more or less permanent degree. 

During convalescence from insanity the scales may drop 
suddenly from the mental vision, but more often the return to 
the normal is gradual. Delusions hang over like dream pictures, 
even when the patient seems nearly rational, and he is for some 
time in that hazy state of being unable to distinguish between 
the real and the imaginary. This readjustment to normal 
mental life is usually painful ; the mental changes necessary to 
recognize and correct the false impressions are often tediously 
made, and the struggle between the fantastic and the real has 
to be gone through with alone. " Therein the patient must 
minister to herself." 

When we say that insanity is a modification of the personality, 
it does not mean that the one so affected becomes another in- 
dividual. He keeps, of course, his same body and brain, but 
certain minute changes have taken place ; his physical and 
psychical life have undergone changes, although the changes 
are usually along the same lines that characterized the person 
in his normal mental state. In other words, his abnormal 
mental condition is largely an exaggeration of his tendencies 



Chap. XXIII] NORMAL AND ABNORMAL MENTALITY 291 

and predilections in the normal. Previous faults of character 
and of temper manifest themselves in greater intensity now. 
The sloth that was one of the besetting sins, the selfishness, the 
obstinacy, the uncontrollable temper, or the suspicious nature 
— these manifest themselves in greater proportions than for- 
merly, dominating the mentality. In those who are of gentle 
disposition we often see gentleness degenerated into weakness and 
fatuousness; those inclined to sadness develop the profound de- 
pressions ; those given to magnifying every ailment become victims 
of hypochondria. The person with a so-called natural intolerance 
for pain, who frets and storms till the family or the doctor do some- 
thing to relieve it, who is impatient of delays and cannot brook any- 
thing less than immediate palliation, is of the type that needs to 
guard especially against becoming an alcoholic or a drug habitue\ 
The fates of these self-indulgent natures who fly to drugs and 
stimulants for relief from pain and ennui, and so become their 
victims, reminds us that " we must learn to do without our 
opium,' ' and, as George Eliot says, to endure pain, if need be, 
with " conscious, clear-eyed endurance." 

There is no standard of sanity and insanity. Certain beliefs 
and manifestations that would be madness if held by a person who 
has received a liberal education are simply the natural result 
of ignorance and credulity, or of false theology, or of low asso- 
ciations, in another. Each person has to be judged according to 
his race, class, family, educational, religious, and social standing. 
Many sane persons have delusions; that is, they hold false beliefs; 
but these are the result of insufficient teaching and training, 
and so we call them sane delusions. In the days of the Salem 
witchcraft the belief in witches was held by a large number of 
sane persons, and even to-day in certain rural districts of New 
York State there are whole communities where the people still 
believe in witches. Erroneous as are their views, we know 
they are not insane, they are merely ignorant. But if a person 
who has been liberally educated, who has had the advantages 
of travel and of intercourse with the best minds, through personal 
relations and through books, comes to express the belief that 
she is bewitched, that the doctors are casting a spell upon her, 
and that all sorts of tortures are being inflicted by unseen agencies, 



292 NURSING THE INSANE [Chap. XXIII 

we can readily see that she is suffering from an insane delusion. 
It is contrary to what she believed when her mind worked in a 
healthy way, and she has lost the power to recognize the fallacy 
of such an opinion. 

Mental disorders assume a variety of forms, according to the 
character and extent of disturbance of the different mental 
functions; the trouble may be chiefly in disturbances in percep- 
tion, giving rise to hallucinations and illusions, or in the intel- 
lectual sphere, giving rise to disturbances of memory, disturb- 
ances in the formation of ideas, of the train of thought, of the 
reasoning and judgment, of the rapidity of thought, or of the 
consciousness; or the difficulty may be in the emotional sphere; 
or it may be in disturbances of volition and action. 

The human being is a very complex creature, made up of a 
complicated body in which all the organs and parts working 
together comprise the individual life. We cannot, as I have 
said, think of the body and mind as separate ; they act and react 
upon each other too intimately to consider them apart except 
for convenience in speaking. When body and mind work in 
harmony, when the functions are properly performed, when the 
impressions that come to us from without, and the sensations 
that arise within, are correctly interpreted, that is health — 
health of body and health of mind. Of course there are varia- 
tions within the limits of health ; no one is perfectly sound in 
every part at all times, but we are governed by the predominat- 
ing conditions in speaking of health or disease. When, however, 
there is a prolonged departure from the normal and harmonious 
workings of the various parts, disease exists, and we name the 
disease in accordance with whatever part bears the brunt of the 
disturbance, whether it be heart, lungs, stomach, intestines, 
muscles, blood vessels, nerves, or brain. Yet, let me repeat, 
we need to keep in mind that none of these parts works inde- 
pendently, and all are to varying degrees affected by disturb- 
ances in one another. 



CHAPTER XXIV 

MANIFESTATIONS AND ACCOMPANIMENTS OF INSANITY 

Before studying the more pronounced manifestations of 
insanity it will be well to consider briefly some of the commonly 
observed signs of approaching mental trouble. When these 
signs occur as unusual manifestations in a given person, and to 
such an extent that they become remarkable, we are justified 
in thinking them the result of on-coming disturbance in the 
mental sphere. They are chiefly as follows: insomnia, increased 
irritability, impulsive outbreaks with gradual or sudden loss of 
self-control, destruction of property, injury to self and others, 
defect in the power of attention, lessening of the purposeful 
will power, depression, exaltation, indifference, or maybe apathy, 
neglect of personal appearance, morbid self-centering, erotic 
outbreaks, indecencies, perversions, alterations in the esthetic 
and religious life, unfounded fears, and imperative ideas and 
impulses giving rise to forced actions. Tirelessness is a fore- 
runner of mental breakdown in certain persons, while undue 
fatigue is significant in others. 

It is not, of course, meant that all these symptoms are noted 
in any one case. The above enumeration includes premonitory 
symptoms of widely differing forms of mental trouble. They 
are grouped here that the student may learn what are some of 
the danger signals of mental disorders. 

Broadly speaking, insanity may be spoken of as showing itself 
under four heads: (a) Disturbances in perception (causing 
hallucinations and illusions); (&) disturbances in elaborating 
what has been perceived, as shown in disturbances in the memory, 
in the formation of ideas, in the ability to reason and judge 
correctly, in the rapidity or slowness of thought, and in the 
consciousness ; (c) disturbances of the emotions, and (d) dis- 
turbances of volition and action. 



294 NURSING THE INSANE [Chap. XXIV 

There are also certain accompaniments of these disturbances 
which we shall need to consider, such as changes in the sensory 
and motor functions, in the vaso-motor, trophic, and secretory 
processes, and in the vital functions. 

In some cases disturbances in the emotions may be the pre- 
dominating symptoms; in others, disturbances in the under- 
standing, and in still others, disturbances in the will; and accord- 
ing as one or the other group predominates, we are enabled to 
classify the cases under the various accepted forms of insanity; 
but there are no sharp lines, and we find that disturbances in 
one part of the mentality of necessity affect the other parts more 
or less, and that we must abandon the old notion that a person 
is " insane only on one thing." We must not, however, make the 
mistake of thinking he has lost all his power of mental activity 
because some powers are especially disturbed. But we must 
understand that since all the mental functions are so intimately 
related, the entire mentality is altered when certain functions 
undergo disturbance. I have already, in Chapter XXIII, 
spoken of patients responding to inner stimuli while misinter- 
preting them as stimuli from without. These are disturbances 
in perception. Such responses are due to deceptions of the senses, 
and are, as has been said, called hallucinations. How can these 
hallucinations take place? How can one, for example, hear 
talking when no voice within his hearing is really audible ? In 
order to understand how, we need to keep in mind that all 
sensory impressions, when once stamped upon the brain centers, 
are capable of being re-collected, and that there is what is called 
a sensory memory. By means of this, under certain abnormal 
conditions, the faculty which ordinarily causes sensory reactions 
only to peripheral stimulation may cause those reactions without 
peripheral stimulation. Because the ear has become accustomed 
to hearing voices and the brain centers have registered these 
sounds, and the intelligence has translated them into words 
conveying ideas, and the memory has stored up these sensations 
with the resulting conclusions concerning them — because of 
all these stages, it is possible, in abnormal conditions, to have 
the senses cheated into seeming to sense things which they do 
not sense, and the person, we say, is the victim of sense decep- 
tions — hallucinations and illusions. 



Chap. XXIV] MANIFESTATIONS OF INSANITY 295 

Hallucinations may take place in any of the senses — hearing, 
seeing, smelling, tasting, and touch, so that the person affected 
hears, sees, smells, tastes, and feels things which have no ex- 
ternal objects to evoke them, and yet so vivid is the impression 
made upon him, because of some abnormal excitation in his 
brain cells that are ordinarily only excited by real objects, that 
he feels certain that the things heard, seen, etc., really exist in 
the world outside, though in truth they originate in his own 
brain. He hears some one, for example, say, "He is going 
insane,' ' when no voice within hearing distance has been raised. 
Auditory hallucinations are, as a rule, the seemingly audible 
expressions of the person's own thoughts; dwelling on them 
increases them. 

Hallucinations may arise in sane persons from solitary con- 
finement, fasting, loss of sleep, and other exhausting conditions. 
If the hallucination be recognized as such, we call it a sane 
hallucination; if it cannot be recognized as such, it leads to 
a falsification of consciousness, and becomes an insane halluci- 
nation. In some instances patients can recognize them as at 
least very unusual, and so are often capable of concealing their 
existence for longer or shorter periods, as the case may be. 

Illusions are also deceptions of the senses, but they have an 
outside object as a starting point. The patient really hears, 
sees, tastes something, but thinks it is other than it is. He 
misinterprets it. For example, he hears the escape of steam, 
and thinks it is some one hissing at him ; an engine whistles, and 
he thinks it is the cry of his tortured child. His sense impres- 
sions are as correct as ever, but the judging power is at fault. 
Some persons may experience illusions, but by bringing closer 
investigations and judgment to bear on them are able to correct 
the false impressions ; this, as a rule, the insane cannot do. 

Both hallucinations and illusions, when believed in as real, 
give rise to false beliefs or delusions, of which more will be said 
when speaking of disturbances in elaborating what has been 
perceived. 

Hallucinations of all the senses may occur at the same time, 
or there may be disturbances in only one or two or more fields. 
Those of sight and hearing are most frequently observed. As 



296 NURSING THE INSANE [Chap. XXIV 

a rule, the hallucinations of sight occur in acute insanity, and of 
hearing in chronic insanity. Visual are less grave than auditory 
hallucinations. Sometimes patients speak of hearing the words 
spoken in their heads, or abdomens, or close to the ear, or on 
their tongues, instead of in the outside world. Sometimes 
they speak of telegraphing or telephoning taking place in their 
brains. Hallucinations of smell and of taste ar.e usually un- 
pleasant in character ; they are more common in the chronic 
than in the acute forms of insanity. Those of hearing and of 
sight may be agreeable, or the reverse. Unpleasant hallucina- 
tions often give rise to dangerous conduct on the part of their 
victim. Hallucinations of smell are often associated with dis- 
orders of the sexual sphere, and are found in many patients 
given to excesses and perversions. They are also seen in the 
toxic infections, in certain organic lesions, in hysteria, epilepsy, 
and other functional disorders. Hallucinations of taste are 
frequently found with delusions of poisoning — the patient 
imagines he tastes arsenic, copper, and the like, in his food. 

It is difficult to distinguish between hallucinations and illu- 
sions of touch; real bodily sensations probably often give rise to 
the patient's belief that he is being tortured by unseen wires, 
covered with poison, molested by some one visiting him at night, 
and diverse complaints of this nature. These perversions of the 
common sensibility are spoken of as somatic sense deceptions. 

Disturbances in elaborating what has been received in the 
mind through sense impressions depend largely upon the im- 
pairment of the memory. It is by means of the memory that 
we are able to recall former impressions and so form concepts 
or ideas of objects previously perceived. Memory is dependent 
upon three things : the vividness with which we are impressed 
with things presented to our minds, the power of retaining 
things presented, and the capacity to reproduce the impression. 
Anything which affects the normal reproduction of ideas affects 
the memory. The ideas may come so quickly into the mind 
that each one gets effaced because there are so many, or there 
may be conditions in which something interferes with the 
formation of memory pictures. In excited cases we see facili- 
tated reproduction of ideas, so that things previously experi- 



Chap. XXIV] MANIFESTATIONS OF INSANITY 297 

enced and things experienced at the present time crowd so close 
that a jumble of ideas results. Where there is interference with 
the reproduction of ideas, we get periods of loss of memory 
{amnesia) varying in degree from the slight loss due to mental 
fatigue, through all the gradations noted in the profound de- 
pressions, in hysteria, senile dementia, and general paresis. 

In some instances the power of retaining new impressions is 
impaired; the patient cannot remember a name or number or 
color for half a minute. In the mental disorders due to old age 
we see lack of impressionability concerning things that are 
happening to the patient now, but with ability to recall events 
long past. 

When the accuracy of memory is disturbed, we see the patient 
unconsciously distorting facts when telling them, or he may 
mix real experiences and imagined experiences together without 
knowing it, or may deal in fabrications which are really hallu- 
cinations of memory — the patient weaving an account of things 
often improbable and contradictory, that never existed, yet 
doing this all unconscious of the untruth. Hysterical patients 
will often give the most remarkable account of things they have 
done, which, all unknown to them, are untruths "out of whole 
cloth/ ' as the saying goes. An excess of the imaginative faculty 
in some children, as in hysterics, accounts for these confabulations. 

When the disturbance is in the intellectual sphere, there 
may be abnormally slow thought, or abnormally rapid thought, 
giving rise, in the one case, to dearth of ideas and dearth of 
expression, with a depressed emotional state, and in the other 
case, to a rapid flow of ideas and a more and more jumbled way 
of expressing them as the disorder progresses ; this latter con- 
dition being accompanied by an exalted emotional state. Slug- 
gish thought and slow, halting speech, or no speech at all, is 
opposed, in the one condition, to rapidity of thought and full 
speech, with a flow of words increasing to a disconnected flight 
of ideas, till finally the association between the ideas can no 
longer be traced by the bystander. Such a stream of thought 
is called incoherent. 

Other disturbances in the intellectual sphere are seen when 
troublesome and annoying ideas (imperative ideas), recognized 



298 NURSING THE INSANE [Chap. XXIV 

as absurd by the patient, are held in spite of all efforts to dis- 
miss them. These come into the consciousness spontaneously, 
cropping out seemingly regardless of any association, and 
disturbing the regular train of thought. Such patients are 
miserable unless they yield to these persistent ideas. They 
must wash their hands so many times before touching anything, 
lest they contaminate it, must count so many times before under- 
taking a certain task, must step on a certain crack in the floor, 
or on a certain flower in the carpet, or they cannot get it out 
of their minds, as they say, and so are dominated by it. 

When a person holds a belief that is false — a belief that has 
arisen because of some disturbance in his perceptions, and in 
his ability to correctly interpret them, and when he is unable 
to see the error of his false judgment, even when clearly pointed 
out to him, if this false belief is the result of disturbances in 
the structure or function of his brain cortex (and not from 
ignorance or superstition), we say he has an insane delusion. 

Sometimes the conduct of others, wrongly interpreted, is the 
starting point for the wrong belief, sometimes bodily sensations, 
disturbances in some of the organs, cause the patient to build 
false beliefs upon them. For example, rheumatic twinges may 
be interpreted as pains from concealed wires applied to torture 
the patient, and sometimes false impressions received from the 
various senses come in time to be falsely judged by the patient. 

Delusions may be depressive or exalted. Patients may feel 
themselves abused and persecuted, or they may falsely believe 
themselves to be very unworthy, or dead to the world, or pos- 
sessed by demons, or they may believe that all their organs are 
turned to stone, or are otherwise incapable of performing their 
functions. These are all examples of degressive delusions. On 
the other hand, the false beliefs may take on an expansive char- 
acter, and the patient believe himself to be some exalted per- 
sonage, some earthly ruler, or some one in close touch with 
the Creator — Jesus, or the Virgin Mary, or if not these, at least 
one specially set apart for work of a divine character. Or one 
may think himself capable of great feats of bodily strength, 
of unprecedented mental vigor, of untold wealth, of marvelous 
inventive, artistic, or executive ability. 



Chap. XXIV] MANIFESTATIONS OF INSANITY 299 

We speak of delusions as fixed or transient according as they 
are temporarily or constantly present in the consciousness. 

An insane delusion cannot be persistently held except there 
is a grave disturbance of consciousness, making clearness of 
judgment impossible. It matters little what the patient be- 
lieves, nor how many false beliefs he holds ; the fact that he holds 
any one false belief and holds it persistently and is unable to 
correct it, shows him to be insane, even though many of his 
mental faculties appear to be in their usual working order. 

There are various ways in which the consciousness of the patient 
may show disturbance : in excessive self-consciousness, in absent- 
mindedness, in difficulty in sensing his own consciousness, so 
that he regards himself as an external object, and speaks of him- 
self in the third person, in inability to comprehend where and 
who he is, and what the year, the month, and the day are, who 
the persons are about him, and his relations to them and the 
external world in general (disorientation). Or certain other per- 
sons may have breaks in their consciousness; a given person 
may undergo a peculiar breaking up of the consciousness as 
a whole, some parts separating themselves from others in a way 
to make virtually two personalities instead of one, the patient 
becoming alternately one and then another personality, with 
no memory to bridge over the transition from the one to the 
other. A dual life is thus lived by one being, a Dr. Jekyll and 
Mr. Hyde existence. Or there may even be a breaking up into 
more than two personalities. Well-authenticated cases are on 
record where such multiple personalities inhabit the one body, 
the one individual in turn playing many parts, according as the 
different consciousnesses come to the surface. Cases of true 
hysteria come under this head of dual and multiple personalities. 
Other conditions in which consciousness is disturbed are seen 
in slight cloudiness, in dreamy states, in the stupor of epilepsy 
and of other conditions, in ecstasy, and in certain alcoholic 
psychoses. 

We are wont to speak of mental reduction in connection with 
certain cases. By this we mean a loss of power of connected 
thought, a dulling of all the faculties, a loss of interest and 
emotion, a weakness of memory, falsification, and confusion of 



300 NURSING THE INSANE [Chap. XXIV 

ideas which give rise to imperfect grasp of matters pertaining to 
self and surroundings, and a diminution of the sense percep- 
tions. When this is profound, we see the apathy and listless- 
ness and the dearth of ideas — in short, the condition that we 
usually characterize as terminal dementia. 

We have in disturbances in the emotional field abnormal 
feelings — feelings arising without sufficient cause, or, if with 
sufficient cause, out of proportion to the cause. There are 
abnormal painful emotions, and abnormal pleasurable ones. 
When the impressionability is too keen, the slightest causes 
give rise to exaggerated responses of either pleasure or pain, 
or adequate causes are responded to with emotions entirely 
out of proportion to the exciting cause. Laughter and weeping 
are too easily evoked, bodily pleasure or pain too keenly felt, the 
beautiful and the ugly give rise to extreme hypersensitiveness; 
objects and persons are too violently admired and adored, or 
disliked and abhorred; exaggerated sympathy for others is 
felt, and extravagant conceit or suffering, as the case may be, 
is experienced at compliments or reproofs. Or if, instead, there 
is emotional dullness, things ordinarily responded to are regarded 
with indifference — friends, work, obligations; the person's 
feelings are blunted ; he may feel himself dead, or inhuman, or 
changed or unreal. He may lose his former esthetic feelings. 
He may respond in a perverse way to things that ordinarily 
would call forth an opposite kind of reaction. For example, the 
odor of a delicately scented flower may cause disgust, the sight of 
a former friend, hatred, while the patient may take delight in 
swallowing obnoxious substances, in tasting unclean things, in 
witnessing suffering, or in profaning objects hitherto held sacred. 

Patients under the dominance of abnormally depressed moods 
are often capable of understanding their changed states, and 
suffer because they cannot suffer, as it were. They feel bad 
because they no longer suffer at being separated from their 
home and friends. Nothing seems real to them, nothing touches 
them intimately, or rouses them sufficiently to awaken the 
natural feelings, so they say they are changed and unreal — all 
sense of reality is lost in some persons ; a wall or barrier looms 
up between them and everything. 



Chap. XXIV] MANIFESTATIONS OF INSANITY 301 

In the face of exaggerated emotional tone it is difficult even 
for a sane person to judge correctly. In fact, the greatest 
proof of soundness of mind is one's ability to suspend belief in 
the presence of an exciting emotion — to weigh and judge cor- 
rectly, dispassionately. Untutored minds cannot do this, 
prejudiced minds cannot, unsound minds cannot. Emotion 
and imagination sweep away reason. The person under their 
sway believes because he is stirred, moved, and wants to believe, 
not because his highest power — the judging faculty — coerces 
him to believe. The intensity of one's belief is no proof of its 
truth, except to the misguided believer. The fire of the moment, 
the emotion, burns up all else, so that only the emotion seems 
the reality. This intense emotion is accompanied by a bodily 
commotion ; the person thinks, " Nothing which I feel like this 
can be false." Most supernatural beliefs come about in this 
way ; persons prone to succumb to them are seized with a mental 
vertigo that prohibits the exercise of their judging faculty. 
This is the type of mind that makes possible the fanatic and the 
mystic. Of such unstable types are mobs created, and from 
this uncritical way of regarding things arise the impulsive crimes 
that shock society — reason in abeyarfce, emotion in the ascend- 
ancy. Given these conditions, the results are only a question of 
degree, and depend upon the experiences and environment of 
a given individual, and the trend that his emotions take. They 
are alike in kind ; they differ only in degree; reason is dethroned ; 
emotion is the usurper; indiscriminating and ill-regulated con- 
duct must follow. 

In observing the manifestations of abnormal emotional states, 
we need to remember that feelings of agreeableness or dis- 
agreeableness are quickly reflected in the brow and eyelids. 
Form a habit of studying these reactions in the sane as well as 
in the insane. In self-satisfaction and in self-debasement how 
opposite the facial expression and carriage of the body ! In the 
one all is expansion, in the other all is contraction. In the 
one the person obtrudes himself upon the notice of all; in 
the other he crouches and shrinks from observation. 

In diseased conditions where the impulses and the will suffer 
chiefly, we get unnatural and irrational acts as a result. The 



302 NURSING THE INSANE [Chap. XXIV 

appetite for food, the sexual instinct, self-preservation, and 
other normal instincts, undergo change. The appetites may be 
increased or lessened or perverted. Patients may eat voraciously, 
or refuse food, or eat disgusting things. In the sexual field this 
is seen in excesses, in unwonted abstinence, or in indulgence 
in self-abuse or in still more abnormal practices, such as perver- 
sions with the opposite sex or with the same sex. Or there may 
be apparent absence of ordinary healthy sexuality, and the 
abnormal sexual feeling may show itself in undue coquetry, 
exaggerated attention to personal adornment, inordinate use 
of perfumes and pomades, suspicion concerning the virtue of 
others, constant conversation about marriages, scandals, and 
sexual topics, harping on symptoms referable to the pelvic 
organs, or in excessive religious observances ; these are all con- 
sidered sexual equivalents, manifestations of the extent to which 
the disordered sexual instinct is influencing the life. 

Impulsive acts are those which result without the ideas which 
give rise to them being clearly defined in the consciousness; 
therefore we say of such acts that they are without motive and 
are incomprehensible. These are common in cases of arrested 
development, as in idiots and imbeciles ; in hysterics, epileptics, 
and persons crazed by drinks; in organic brain diseases, and in 
excited and depressed cases where the governing power of the 
individual is no longer capable of exerting its customary re- 
straint. In these impulsive outbreaks the thought is immedi- 
ately translated into an act without the intervention of the 
will. 

Maniacal persons "do the first thing that comes into their 
heads," regardless of consequences. Depressed patients often 
make agitated, restless, perhaps absurd motions, which are 
really reflex movements set going by the painful feelings and 
the abnormal workings of their brains. Demented patients 
strike themselves, pull things to pieces, rub off their hair, pull 
it out, walk in one place habitually, or perform other stereo- 
typed movements that are automatic, that have come to be 
muscular habits uninfluenced by the will. 

Other disorders affecting the will are those of abnormally 
increased and abnormally lessened will power, resulting in the 






Chap. XXIV] MANIFESTATIONS OF INSANITY 303 

one case in obstinacy, in the other in powerlessness to determine 
a course of action and hold to it. 

The insane present disturbances in speech varying with the 
different psychic conditions already described. There may be 
increase in the rapidity of speech, from merely a rapid flow to 
actual incoherence, or the speech may be slow and stuttering; 
or there may be mutism (not deaf-mutism, but a condition 
of being mute dependent solely upon disturbance of the mental 
life); there may be inability to say certain words, or to put the 
right word in the right place (aphasia) ; there may be silly affected 
speech, baby talk, senseless jargon, and gibberish, or wearisome 
repetition of a word or a phrase (verbigeration), or coining of 
words to correspond to certain abnormal feelings that arise, or 
difficulty in pronouncing certain words, due to muscular weakness ; 
for example, the slurring way in which patients with general 
paresis say " Round the rugged rocks the ragged rascal ran," 
and other test phrases put to them. Or there may be scanning 
speech. Unusual associations of words, rhyming, and the mak- 
ing of puns are also among the symptoms often noted. 

Other manifestations of insanity are seen in disturbances of 
the sensory and motor functions, in vaso-motor, trophic, and 
secretory disorders, and in disturbances in the vital functions. 

Under disturbances in the sensory functions we see conditions 
of anesthesia and hyperesthesia — certain parts show lessened 
sensation or loss of sensation to touch, to heat and cold, and to 
pain, or they may show increased sensation, so that the lightest 
touch gives rise to pain, and all cutaneous impressions come to 
them with increased force. Neuralgias may accompany insanity. 
Anesthesias are noted in hysterical and demented patients and 
in those suffering from organic nervous diseases. Patients 
undergoing mental reduction show a dulling of their sensations ; 
they are often inattentive to heat and cold, indifferent to the 
taking of food, and to evacuating the bowels and the bladder. 
Certain deteriorated patients will stand against a hot radiator 
or put their hands in hot water with apparent obliviousness to 
the burns and scalds that are sure to result unless such are 
carefully safeguarded. The self-mutilations noted in certain 
deteriorated cases is due to this want of normal sensation. 



304 NURSING THE INSANE [Chap. XXIV 

Localized areas of anesthesia as to pain, touch, and temperature 
are seen in hysterics, and in patients suffering from organic 
lesions of the central nervous system, in general paresis, and 
senile and alcoholic cases. When patients are anesthetic they 
often burn or maltreat themselves severely; when they are 
hyperesthetic they cannot endure even the gentlest handling 
of the affected parts. 

Motor expressions of insanity are seen in the various facial 
expressions, carriage and posture of body, station, gait, the 
altered reflexes, in tremors, spasms, convulsions, choreic move- 
ments, tics, paralyses, contractures, and failure of coordination 
of the muscles. To illustrate a few of these motor expressions 
we need only to recall the troubled, wrinkled face of the melan- 
choly patient, the changing vivacity of the maniacal one, the 
proud bearing and supercilious expression of the patient with 
grandiose delusions, the swimming eyes and the too ready smile 
of the hysteric, the careless gait, fatuous smile, and generally 
dilapidated appearance of deteriorated patients, and the wander- 
ing, perplexed air and restless dissatisfaction of senility. 

Disturbances of the deep reflexes are found in melancholiacs, 
in anemic persons, in general paretics, in senile patients, in 
epileptics, and in persons with dementia praecox. The knee 
jerks are usually sluggish in depressive forms of insanity, and 
exaggerated in manias, exhaustion cases, and in dementia prae- 
cox. The absence of eye reflexes, the failure to react to light, 
in most instances indicates some organic brain disease. Ex- 
aggerated superficial or skin reflexes are common in hysterical 
and neurasthenic patients. 

Lack of innervation of the facial muscles is seen in the irregular 
movements around the corners of the mouth and the eyes, 
irregular wrinkling of the forehead, etc. Alcoholic cases, general 
paretics, and terminal dements furnish examples of these move- 
ments. Tremors are of various kinds and may indicate many 
and diverse conditions. They may be the result of anxiety, 
fear, or other nervous excitement, may be dependent upon 
anemic states, or they may indicate alcoholism, general paresis, 
or sclerotic brain affections. Convulsions may affect single 
muscles, an entire limb, or they may be general. When coming 



Chap. XXIV] MANIFESTATIONS OF INSANITY 305 

on for the first time in middle life, they usually indicate advancing 
organic brain disease. 

Disturbances in the articulation due to motor states are noted 
in alcoholism, general paresis, syphilis, and other grave conditions. 

Muscular incoordination is seen in alcoholism, in general paresis 
after apoplexies and injuries, in brain tumors, etc. 

Stereotyped attitudes and movements are common to a large 
number of the insane. These may be of some part of the face, 
of the limbs, of the voice or speech, of the carriage, posture, 
or gait — in fact, since the basis of stereotyped movements is 
to be found in common, everyday acts, the movements them- 
selves are correspondingly varied. Among some of these move- 
ments are the following: screwing up one eye, pursing out the 
mouth, chewing the tongue, lifting the skin of one half of the 
forehead, blowing out the cheeks, swallowing air, holding the 
head forward in turtle fashion, rubbing a part of the body 
automatically, making peculiar meaningless gestures and motions 
with the arms and hands, swaying the body rhythmically, speak- 
ing in a high-pitched or otherwise affected voice, prefacing 
certain words with queer guttural sounds, or whisperings — 
these are only a few of the innumerable stereotyped ways you 
may note in long-standing deteriorated cases. These movements 
probably started as the result of some insane idea, and were 
consequently voluntary, but have persisted so long that they 
have become automatic, and in most cases the idea that gave 
rise to them has probably ceased to appear in the consciousness 
of the patient. We call these peculiar stereotyped movements 
mannerisms. 

Another condition associated with impairment of the voli- 
tional sphere is negativism. This may be of only a mild degree, 
or may be very extreme. It may show itself in a patient's keep- 
ing his eyes closed, in turning away the head when spoken to, 
in walking or drawing away the minute he is approached, in 
creeping out of sight, in refusing to eat, or to void urine or feces 
for long periods; in short, in responding in just the opposite to 
the natural way to the various stimuli offered. 

Mention has already been made of imperative ideas coming 
into the consciousness and dominating everything, even when 



306 NURSING THE INSANE [Chap. XXIV 

the patient is capable of recognizing the absurdity of them. 
Out of these imperative ideas, or obsessions, grow imperative 
acts. Certain suicidal attempts and homicidal attacks come 
under this head, but certain others are the outcome of deliber- 
ation. 

Vaso-motor manifestations are frequently the direct result of 
emotions; among these we see the temporary palings and flush- 
ings, blueness and swelling of parts, skin-writing, disorders in 
the [pulse, pain, pressure, and anxiety referable to the heart, 
with palpitation and globus hystericus, or a feeling of a ball in the 
throat. Trophic disorders are often an accompaniment of in- 
sanity. By these we mean disturbances in the nutrition of a 
part. This may have taken place during development in the 
uterus, or later in life. The malformations of the bones and 
soft parts that persons are born with come under the head of 
trophic disorders, such as a lack of symmetry in the bones of 
the face, head, or other parts, poorly placed and irregular 
teeth, harelip, cleft-palate, imperfectly formed ears, hypertrophy 
of parts, and other anomalies too numerous to mention. Some 
of the trophic disorders developing later are obesity, abnor- 
mal growth or loss of hair, pigmentations, bed sores, inflam- 
mations of joints, abnormal brittleness of bones, and trophic 
changes in skin and nails. Of course many of these condi- 
tions are also seen in persons who are not now and are not 
likely to be insane. 

In regard to altered secretions to be noted among the insane, 
there are lessened secretions in depressed cases, as a rule, and 
increased secretions in excited cases. Acute cases naturally 
show more variations than chronic ones. Some depressed 
patients cry and moan and are consumed with grief, yet the 
secretion of tears is often very scanty, while in excited patients 
we see the bright glistening eyes due to active secretion, even 
though they do not overflow with tears ; and in erotic cases it 
is no uncommon thing to see the swimming eyes that indicate 
exaggerated secretion. 

Increased and decreased secretion of urine and of saliva are 
also noted. Manic cases in the height of their attacks are 
especially prone to the expectoration of saliva. Demented ones 






Chap. XXIV] MANIFESTATIONS OF INSANITY 307 

may hold saliva in the mouth or let it dribble from the corners ; 
this is not due to increased secretion, but rather to stupor and 
neglect to swallow, or, in some deluded patients, to delusions 
concerning the value of, or disposal of, the saliva. Depressed 
patients may have cessation of the menses, owing to anemia 
or other causes that reduce the nutrition, and the reestablish- 
ment of this function usually takes place when the physical 
health is sufficiently improved to admit of it. As a rule, it is 
not that the insanity causes the cessation of the menses, or the 
cessation of the menses that causes the insanity, but that both 
these symptoms are due to disorders of nutrition. 

We need in the conclusion of this study of the manifestations 
of insanity to consider further how the vital functions undergo 
changes which are in part causes and in part accompaniments of 
insanity. 

The temperature, as a rule, does not show conspicuous devia- 
tions from the normal, unless there are accompanying disturb- 
ances in the vegetative organs. Still, in certain congestive con- 
ditions — in epileptic attacks, in apoplectic seizures, in general 
paresis, in delirious cases, and in certain nervous states — we see 
increased temperature, while in advanced general paretics, and 
in stuporous cases, there is often subnormal temperature. The 
pulse, however, may show great variation, dependent upon 
the emotional changes as well as upon whatever bodily conditions 
may be present to affect it. The respiration is very variable, 
and is greatly influenced by the emotions. Agitated cases of 
depression may show very shallow and rapid breathing, stupid 
cases with dulled emotions, slow and insufficient respiration, 
and certain deluded persons controlled by false beliefs will try 
to hold their breaths as long as possible, and to breathe no 
deeper and no more frequently than they can possibly help. 
Such practices, if persisted in, favor the development of phthisis. 
Certain patients with an hysterical tendency frequently present 
remittent, jerky, and exaggerated respiration, largely voluntary; 
while others with organic brain disease show remittent and 
disturbed breathing of an involuntary nature. 

Digestion and assimilation are often surprisingly good in mildly 
excited cases, while in the depressed these functions are usually 



308 NURSING THE INSANE [Chap. XXIV 

sluggishly performed. Likewise, the general nutrition is often above 
par in mildly excited cases, while in profoundly excited and in 
depressed patients, during the height of disease, the bodily weight 
is likely to be reduced, and Improvement in the mental state is 
usually accompanied by improvement in nutrition also. 

Disorders of sleep are common in the early stages of most 
mental troubles. Certain excited patients may go with little or 
no sleep for weeks without showing signs of exhaustion, although 
if proper care and nursing are given, such protracted insomnia is 
unnecessary. Depressed cases, especially of the agitated variety, 
sleep poorly. Because their sleep is unrefreshing, they believe 
that they have not slept at all, or they may assert that the sleep 
was not natural, but was the result of drugs, when such is not the 
case. Senile patients are especially prone to nightly restlessness. 
The majority of chronic patients sleep well, provided that they 
are hygienically cared for, with due attention paid to their evac- 
uations, to their nourishment, cleanliness, bed coverings, and 
ventilation. 



CHAPTER XXV 

FORMS OF MENTAL DISEASE 

At this stage of psychiatry when dissatisfaction concerning old 
classifications of mental diseases is so marked, yet when those 
who are making the most thorough and painstaking study of the 
various disease-types are loath to offer a new classification, it 
seems presumptuous to attempt a description of the various 
psychoses under any definite names — these names and these 
disease-types being still so fruitful a source of discussion and 
difference of opinion. In the study of mental diseases it is 
much more important to observe each case closely, and gather 
together the distinguishing facts concerning it, than it is to give 
it a name and compel it to come under that head, when perhaps 
it presents certain features that make it difficult to put it in any 
of the well-defined groups. 

Fortunately the complicated questions that puzzle the psy- 
chiatrist need not disturb the nurse, and for her purposes I have 
thought it best to take up some of the commonly met and gen- 
erally accepted forms of mental disease and briefly describe 
them, omitting the rarer forms and leaving the various considera- 
tions that puzzle the psychiatrist entirely out of the question. 

Exhaustion Delirium. — A collapse delirium following some 
condition which has produced profound exhaustion may cause 
the patient to be sent to a hospital for mental diseases, although 
most of such cases pursue a rapid course (two or three weeks) 
and may be cared for at home. Exhaustion delirium frequently 
follows childbirth, severe loss of blood, excessive mental strain, 
and certain acute diseases, as pneumonia and the various infec- 
tive fevers. 

The principal symptoms in these cases are loss of sleep, followed 
by great restlessness and clouding of consciousness; the patient 

309 



310 NURSING THE INSANE [Chap. XXV 

does not know where she is, and does not recognize her friends; 
she has dreamy hallucinations, illusions, fears ; the talk is in- 
coherent, the delusions are likely to be changeable and of an 
exhalted or a depressed character; impulsive acts of violence, 
immodest behavior, and unreasoning resistance are common 
manifestations. These are accompanied by weakness, greatly 
reduced nutrition, tremor, subnormal temperature, weak and 
irregular pulse, and usually exaggerated reflexes. The cloudiness 
of consciousness disappears suddenly as a rule, and as the 
physical condition improves the other mental symptoms sub- 
side. 

More profound cases of mental confusion present similar 
symptoms, but run a much longer course — two or three months. 

Intoxication Psychoses. — Intoxication psychoses are mental 
diseases due to the toxic effects of alcohol or drugs. The 
infection may be acute or chronic. The manifestations depend 
upon the quantity and character of the poison taken, upon 
the susceptibility of the one taking it, and upon the length of 
time he has indulged in the use of the poison. Alcohol, mor- 
phine, and cocaine are the toxic substances we shall consider 
here. 

Acute Alcoholism. — Acute alcoholism at first makes its vic- 
tim experience an unwonted sense of well-being; his mind works 
rather more quickly than usual; he becomes talkative, gay, and 
lively; he thinks he is being very funny and even witty, when 
perhaps he is uttering the most commonplace remarks, or reiter- 
ating the most fatuous statements. The emotions are very un- 
stable in these cases; the person laughs, sometimes at the least 
little thing, weeps, or grows sentimental or maudlin, gets angry 
at the slightest cause, and becomes profane, obscene, abusive, 
threatening, and may be violent. At first he feels himself 
stronger than usual, often boasts of his great power or his in- 
tellectual ability, his high standing, his wealth. He loses all 
sense of decency and propriety. The exaggerated feeling of 
strength and well-being soon passes; his movements are poorly 
controlled ; his conduct becomes more and more reckless ; his 
smile a besotted grin ; his speech thick ; his intellect more and 
more dulled ; his gait staggering ; and a temporary paralysis 



Chap. XXV] FORMS OF MENTAL DISEASE 311 

may supervene, the person becoming insensible and unconscious. 
After sleep he wakens with headache, weakness, nausea, and 
loss of appetite. 

Chronic Alcoholism. — Chronic alcoholism shows itself in grad- 
ual and progressive mental deterioration and in certain physi- 
cal changes that show the deplorable effects of the poison on the 
central nervous system and on the bodily organs and functions. 

Persons so afflicted are poorly equipped with power of resist- 
ance, either because of defective hereditary endowment, or be- 
cause factors in their early development have rendered them 
unduly susceptible to toxic substances, so that they are profoundly 
affected by an amount that would only cause a mild exhilaration 
in a more stable organization. For such unstable persons there 
can be no half-way course. They cannot be temperate. They 
must be total abstainers, or else must suffer the slow physical 
and mental deterioration that alcohol inevitably produces in such 
individuals. 

Lessening of the moral sense is one of the most conspicuous 
features. The person gradually undergoes a change in char- 
acter, he becomes untruthful, loses his finer sense of honor, 
little by little grows lax about things concerning which he was 
formerly most particular ; his ideals dwindle ; he sees those de- 
pending upon him suffering want and shame, yet pursues his 
downward course, seemingly indifferent to their needs or their 
entreaties. Sometimes he falls so low that he will pawn the 
clothing and food his wife has earned, in order that he may pro- 
cure money to buy another drink. 

The mental enfeeblement is slow but progressive. At first 
the person feels unable to apply himself to the tasks he formerly 
did with ease ; his mind wanders ; he has a growing sense of 
fatigue ; later he shows impairment of judgment, poverty of ideas, 
and gradual failure of memory. As the condition progresses 
he may develop delusions of a persecutory nature. Along with 
the above symptoms muscular weakness is apparent; a fine 
tremor may come to be a pretty constant symptom ; frequent 
headaches, dizziness, difficulties in speech and gait, are common, 
and convulsive seizures of an epileptoid character may appear. 

Delirium Tremens. — Delirium tremens is an alcoholic psy- 



312 NURSING THE INSANE [Chap. XXV 

chosis marked by the development of hallucinations, chiefly of 
sight and hearing, by fleeting delusions, chiefly of fear, and often 
by clouding of consciousness. This disease sometimes develops 
when the patient has had no alcohol for several weeks ; in other 
cases when the patient first abstains, in others when he is still 
drinking. It is usually preceded by loss of appetite, vomiting and 
gastric pains, insomnia, restlessness, fear, bright spots before the 
eyes, and occasional hallucinations at night. As the disease 
develops, the hallucinations become prominent; first annoying, 
then terrifying. All sorts of animals are seen coming nearer and 
nearer — bugs, rats, snakes, or strange fantastic creatures, gro- 
tesque faces peer at him ; devils mock him ; an army seems to be 
advancing upon him, mobs revile him, he hears himself called 
vile names by his acquaintances, and taunted with all sorts of 
things. 

It is only rarely that the hallucinations and illusions take on 
a pleasing character, but occasionally the patient thinks God 
appears to him and commands him to do some great deed, or he 
may hear beautiful music, or see lascivious visions. Later these 
false perceptions become fewer and less prominent, and the 
patient is able to recognize them as hallucinations and illusions, 
after which they cease to trouble him and soon disappear. As 
a rule the patient only half comprehends where he is ; everything 
is interpreted in a confused and contradictory way; the time- 
sense is much interfered with, while the memory for recent 
events is very poor. Sleeplessness is a common symptom. 
The nutrition is very poor and, as in the other alcoholic states, 
gastric symptoms are prominent. The disease may last only 
a few days, or from two to three weeks. A few hallucinations 
may hang over for some time, but having acquired insight con- 
cerning them, the patient is no longer annoyed by them. 

Alcoholic Delusional Insanity. — Alcoholic delusional insan- 
ity is recognized by the sudden development of delusions of 
persecution, which are based upon hallucinations of hearing. 
In this disease the patient retains a clear consciousness. The 
trouble comes on with nightly aggravations, the patient hears 
people shouting, crying, perhaps hears bells ringing, or reports 
of firearms. Later the shouting seems to refer more particu- 






Chap. XXV] FORMS OF MENTAL DISEASE 313 

larly to him; he hears his name called, thinks his fellow-work- 
men or his cronies are in the next room talking about him; 
hears references to past shortcomings, or accusations concerning 
things he never did. He may hear persons saying that his wife 
is unfaithful to him, or that he and his children are to be mal- 
treated or murdered. He may experience hallucinations and illu- 
sions of sight, also, especially at night, see flashes or spots of light, 
grotesque faces, creeping and crawling animals, and so on. In 
some of these cases hallucinations of smell and taste are also met. 

The patient suffers horribly in this disease. He feels himself 
the unpopular center of attraction. He thinks he is being 
watched, followed, jeered at, about to be arrested, executed, or 
murdered. Sometimes in his terror of imaginary persecutors 
he goes and implores the protection of the police, believing that 
malefactors are hot upon his track, and in this act his insanity 
is first suspected. For these cases appear rational, they appre- 
hend clearly all that is really happening around them, can talk 
coherently, and it is only when investigation proves that their 
fears are unfounded, that their real state of mind is discovered. 

This disease may run a short or an extended course — from two 
to three weeks in acute cases, or from two to ten months in 
protracted ones. 

Some cases of chronic alcoholism develop delusions of jealousy, 
independent of the persecutory ideas above mentioned. A man 
so affected gradually comes to suspect his wife of infidelity, and 
every chance look or move that she makes is regarded as 
proof of her guilt. Even her interest in her own father or 
brother may be misinterpreted by him as proof of the depth of 
degradation to which she has fallen; the flicker of a light, the 
rattle of a shutter, a glance out of the window — all are inter- 
preted as signals and secret messages between her and others. 
If hallucinations of taste are experienced, he comes to believe that 
his wife or others are tampering with his food to poison him. 

In these cases, as in the foregoing, the consciousness is clear, 
and, to a casual observer, but little beyond irritability and un- 
stable emotions are noted; and these may be attributed to what 
seem to be the patient's just cause for complaint. It often hap- 
pens that the patient sets forth his suspicions and his reasoning 



314 NURSING THE INSANE [Chap. XXV 

with circumstantial details, so convincingly that he succeeds in 
leading really astute persons to believe him to be a much-wronged 
and long-suffering husband. Suffer he assuredly does, for it is 
as real to him as though it were all true, and his genuine emotions 
together with what seems to be indisputable proof (as he tells 
the story) often lead others to harbor most unjust suspicions 
of the woman he accuses. She, in turn, may not know of his 
suspicions, or, if she does, may be too proud to let his insane 
conduct be known, or may not even realize that it is insane, 
yet, seeing her inability to convince him of her innocence, she 
may suffer in silence all sorts of abuse and threats and accusa- 
tions at his hands. Many a wife, will face repeated danger to 
herself from a husband so insanely jealous, and only ask for pro- 
tection if his threats or acts make her fear for her children's 
safety. It is not at all uncommon for these patients to continue 
living on affectionate terms with their wives while accusing them 
of continuing in their adulterous conduct. Other patients suffer 
so from their false beliefs that they attempt their own lives and 
sometimes those of their wives and the supposed paramours. 
Removal from home scenes is usually followed in time by an 
apparent disappearance of the delusions ; but indulgence in 
alcohol, visits from friends, or return home are likely to be fol- 
lowed by a return of the delusions. 

Morphinism. — Morphinism is the name given to the physi- 
cal and mental deterioration caused by indulgence in the use of 
morphine. The victims of this drug are often to be found among 
physicians, physicians' wives, nurses, and others who, because of 
their intolerance of pain, have sought relief in this way until the 
habit has been imperceptibly acquired. 

The first effect of morphine is to make one think quickly and 
clearly, but this soon passes away and a dreamy state super- 
venes, with numerous changing and fantastic hallucinations and 
illusions; this is followed by a slowing of all the mental processes, 
and a quiescent state in which the patient lives and breathes, 
but seems to experience a temporary suspension of all thought 
and feeling. In some cases these pleasurable effects are not 
experienced, and in their stead, headache, nausea, colic, and other 
uncomfortable symptoms are felt. 



Chap. XXV] FORMS OF MENTAL DISEASE 315 

Persons who continue the use of morphine fail to get the acute 
effects, but they are held in its power because of its ability to 
exhilarate them temporarily enough to make them forget their 
troubles. They find to their dismay, however, that in order to 
get this result they must increase the quantity of the drug, and 
repeat it oftener; and only when the expense has to be reckoned 
with or the difficulties of administration, do they begin to realize 
to what a tyrant they have become enchained. 

In most victims of this drug memory shows impairment, and 
the ability to apply one's self to physical or mental work is dis- 
tinctly lessened. 

The stability of the emotions is conspicuously affected; per- 
sons indulging in morphine are easily dejected and irritated. 
Anxiety, especially at night, is often experienced. They are 
sometimes very stolid, again show very unstable emotions. 

The moral nature undergoes grave changes, even more grave 
than in alcoholism. Patients will resort to almost any measures 
to procure the means for buying the drug. They reach a point 
where they lie unblushingly. They grow more and more in- 
different to work, friends, personal appearance, or consequences. 
They sleep or day-dream by day and grow restless and active as 
night comes on, often reading or otherwise occupying themselves 
all night long to the annoyance of the rest of the household. If 
one ventures to suggest that they do differently, anger and 
obstinacy are easily aroused. 

These patients often complain of numbness, or hypersen- 
sitiveness ; their pupils are usually contracted, their gaze is often 
furtive or staring ; they are usually pale, with marked pallor of 
lips and ears. Some of them get hypochondriacal ; some become 
weak and tremulous, lose flesh, suffer from dizziness, fainting 
spells, profuse perspiration, palpitation. The appetite may suf- 
fer, especially concerning meat; again there may be a ravenous 
appetite, and excessive thirst. Diarrhea and constipation are 
likely to alternate. Victims of morphine often become addicted 
to alcohol also. 

Abstinence symptoms are those which appear on the with- 
drawal of the drug. These are tremor and uneasiness, tickling 
of the nose, sneezing, various peculiar sensations in different 



316 NURSING THE INSANE [Chap. XXV 

parts of the body, obstinate sleeplessness, vomiting, diarrhea, 
perhaps hallucinations, twitchings, convulsions, palpitations, 
fainting, and maybe fatal collapse. 

In favorable cases, as sleep and the appetite improve, the 
symptoms gradually disappear, but convalescence is slow. 

Persons who have been addicted to morphine rarely recover 
permanently, though a few fortunate ones do. Relapses, and the 
tendency to resort to other drugs, must be guarded against. 

Cocainism. — Cocainism is the condition of physical and men- 
tal enfeeblement due to the extended use of cocaine. Victims 
of this drug are quite likely to be addicted to morphine or alco- 
hol also, and are usually persons of an unstable nervous system 
to begin with. 

Cocaine mildly exhilarates at first, much as does alcohol; 
the patient becomes lively and talkative, and feels like under- 
taking things, feels increased mental and muscular power, but 
soon grows drowsy and inactive. Some persons are so sus- 
ceptible to the drug that even small doses are followed by delir- 
ium and collapse. The patient grows pale and sickly looking, 
loses weight, acts sleepy, has no appetite ; he may have twitch- 
ings, tremors, palpitation, fainting spells, and his sleep, poor as 
it is, may be disturbed by hallucinations, followed by delusions 
of a persecutory nature These patients are prone to carry 
revolvers, as they believe it needful to be constantly on guard 
against attack. A characteristic symptom is a feeling as of 
something crawling under the skin. 

Those who become addicted to the extended use of cocaine are 
in a pretty continuous state of excitement, but busy as they are, 
they seem incapable of applying themselves to any effective 
work. They show a deplorably weakened will, a steadily failing 
memory, and much misdirected energy. They are extremely 
loquacious, and are given to writing long letters or articles, and 
are prone to advance many impracticable schemes. Elation 
and depression frequently alternate. Suspicion develops, affec- 
tion for friends diminishes, and they grow callous to all obliga- 
tions and ties. 

In chronic cases, hallucinations of the various senses may 
become distressing, especially those of sight and hearing. Black 



Chap. XXV] FORMS OF MENTAL DISEASE 317 

specks before the eyes, visions thrown on the walls, threatening 
and insulting voices, a feeling of electricity being turned on, or of 
poison being thrown at one, are common experiences. These 
give rise to increased suspicion and suffering, and patients often 
grow to believe themselves the victim of deep-laid plots ; they 
think themselves watched and followed, reviled, tortured, and 
perhaps about to be murdered or otherwise foully dealt with. 
Insane jealousy is a prominent symptom. 

The insanity resulting from cocaine develops rapidly and 
usually runs a course of only a few weeks. It readily recurs on 
renewed indulgence in the drug. 

Dementia Praecox. — A large group of cases is classed under 
the term dementia prcecox — precocious dementia. The major- 
ity of these develop in early life, at the age of puberty, or in the 
adolescent period, and it is from these patients that the bulk of 
the chronic insane population in State hospitals is derived. 

Persons with this disease present many and diverse symptoms, 
only a few of which can be indicated here. There is a strong 
tendency toward progressive deterioration in most instances, 
although a small per cent recover, and others show decided 
remissions of varying duration. 

Physical stigmata are common accompaniments, such as mal- 
formed ears, high-arched and narrow palates, immature childish 
face and figure. 

Among the physical symptoms most commonly noted are poor 
nutrition in the early stages (as deterioration becomes more 
marked many patients grow more and more stout), dermog- 
raphy, increased perspiration, cold mottled hands, dilated pupils, 
exaggerated knee jerks, and amenorrhea. 

Persons who develop dementia praecox, as a rule, have a defec- 
tive heredity, and furthermore have presented symptoms in early 
life that marked them as very different from their fellows — a 
tendency to keep by themselves, to be over-religious, to indulge 
in day-dreaming and immature philosophizing ; often they are 
persons who have been addicted to the habit of self-abuse. A 
lack of application and a general inefficiency seem to have char- 
acterized their course in life. 

Sometimes either an emotional shock, or exhaustion from some 



318 NURSING THE INSANE [Chap. XXV 

acute disease, is the last straw, and the vagaries of the poorly 
balanced organization then rapidly become apparent. In other 
cases, the disease cannot be traced to any sufficient cause. 
Among the early manifestations may be an outburst of excite- 
ment and violence of an impulsive unreasoning nature. The 
patients are silly, often constrained and affected in manner ; they 
express many absurd ideas, chiefly of a sexual and a religious 
nature. Their beliefs are likely to be mystical ; they are inclined 
to attribute their morbid sensations and experiences to the 
influence of others who affect them in some occult way. The 
most improbable beliefs are held unquestioningly. 

A conspicuous discrepancy in the emotions is observed. Silly 
laughter without any appreciable cause is frequently seen. 
Periods of unprovoked anger are common. They fly at the other 
patients, break furniture, destroy clothing, throw their trays, 
and so on, without any purpose back of their acts. These 
persons are apathetic in the performance of their accustomed 
tasks, indifferent to the sorrows of their friends, and often either 
irritably resistive, or provokingly unresponsive to all efforts made 
to awaken interest in things about them. Others may obey 
simple directions or requests, and many can be trained to do 
useful work in a routine way. 

The memory of past events, especially of school knowledge, 
may be surprisingly good, even when the patient is very much 
deteriorated. 

These patients may talk clearly and apprehend well their 
surroundings, or may seem unconscious of their whereabouts, 
or of the identity of their associates. They may speak only in 
monosyllables, or make irrelevant replies, or persistently refuse 
to speak for weeks and months at a time, giving the impression 
that they do not appreciate what is happening. Yet when this 
phase of the disease gives place to another, they may tell accu- 
rately much that happened during the period when they appeared 
oblivious to everything. They may talk and whisper to them- 
selves by the hour, may be given to using stilted, high-sounding 
phrases, or to coining meaningless words. In conversation they 
sometimes show a disposition to trifle and deceive, and to express 
the most absurd beliefs, sometimes the most contradictory 



Chap. XXV] FORMS OF MENTAL DISEASE 319 

ones, without being able to see the utter lack of sense in their 
talk. 

There often seems to be some interference in the ability to 
think — some block in the way, also an inability to distinguish 
the real from the unreal. This gives rise to hazy, puzzled ways of 
looking at things, and our efforts at questioning are often met 
in a perplexed and evasive way. The same inefficiency is shown 
in action ; the person does not easily plan and carry out things, 
but shows numerous evidences of purposeless unconsidered acts. 
If letters are written, they show extreme dilapidation of thought 
in many instances, or, if fairly sensible, they are full of fatuous 
expressions and repetitions. 

Sometimes these patients evince a stealthy curiosity; again 
they may not attend to anything going on around them, but 
instead may stand for hours gazing at a spot in the ceiling, 
smiling ecstatically, listening to the " voices," or seeing visions. 
They take up, from time to time, many oddities, tricks of speech 
or action, senseless stereotyped motions or expressions. One 
patient, for example, will repeat for hours in a slow tone : " Don't 
say nothin', nothin', nothing don't say nothing nothing no thin'." 
Another will grunt or snort, or make chewing motions, or keep 
her mouth pursed up, or walk on a certain board on the floor, 
or assume certain constrained and awkward postures. These 
patients may be stubbornly resistive of everything done for them, 
then as unaccountably yield to persuasion in the most lamb-like 
way. They may refuse food for days; again will show a greedi- 
ness more in keeping with a lower animal than a human being. 

They often seem oblivious to their dearest friends, betraying 
no sign of consciousness of them beyond that of devouring food 
and dainties brought them. Their whole dress and bearing 
betray a dilapidation that is unpromising for mental restoration. 
Self-absorbed, unconcerned, apparently feeling neither joy nor 
sorrow, they often stare for hours into vacancy, wholly occupied 
with the hallucinations that are so prominent an accompaniment 
of this disease. Yet some of these patients show marked im- 
provement, and some make recoveries, though their field of 
usefulness must remain very circumscribed, since their character 
is made up of such flimsy, flaccid material, and their impracti- 
cable schemes are so likely to come to naught. 



320 NURSING THE INSANE [Chap. XXV 

General Paresis of the Insane (Dementia Paralytica). — The 

disease known as general paresis- attacks persons in middle life, 
usually between the ages of thirty-five and forty-five. It is a 
hopeless disease, but there are prolonged remissions in certain 
cases. It is much more common in men than in women, and, 
although authorities vary in their views concerning its causation, 
it is coming to be pretty generally believed that syphilis and alco- 
holism, combined with physical and mental stress, are the chief 
and almost constant causative factors. The disease is on the in- 
crease. Most of its victims come from large cities — men who 
have been under long-continued physical and mental strain, in- 
dulging the while in sexual and other excesses. 

It is a disease in which the definite organic changes that take 
place in the brain and spinal cord are accompanied by steadily 
progressing physical weakness, as well as by progressive mental 
deterioration; both of which processes in time go on to absolute 
paralysis and dementia. Sometimes the physical symptoms 
appear first, sometimes the mental ; again they occur simulta- 
neously. Some of the early symptoms most easily recognizable 
by an untrained observer are: irregularity of the pupils, head- 
ache, vertigo, and epileptiform or apoplectiform convulsions; 
or there may be extreme flushings, distended veins, great rest- 
lessness and irritability preceding the more marked manifesta- 
tions of the disease. The countenance early undergoes a de- 
cided change; the lines of expression disappear, and a fine tremor 
is often seen about the eyes and lips, especially when the patient 
starts to speak. The tongue shows marked tremor ; the voice 
becomes thick and monotonous, later very shaky; increasing 
difficulty in articulating certain sounds is noted, for example: 
" Truly rural," " Third riding artillery brigade," and " Round 
the rugged rocks the ragged rascal ran." A characteristic 
tremor and sprawliness is observed in the handwriting, and 
words are omitted unnoticed by the patient. These muscular 
weaknesses progress until the patient becomes totally disabled 
and bedridden. Some cases remain well nourished to the last ; 
in others, where the nutrition becomes impaired, life drags on 
until the patient is a living skeleton, and bed sores may develop 
in spite of the utmost care, yet death may be weeks in coming 



Chap. XXV] FORMS OF MENTAL DISEASE 321 

to his relief. In this stage, a distressing grating of the teeth is 
often kept up, adding to the general repulsiveness of the wretched 
creature. 

The mental symptoms are extremely varied in different types, 
and at different stages in the disease. At the beginning patients 
may show a dullness of comprehension that resembles that of one 
stupid from alcoholic intoxication. This torpor increases as 
time goes on, but in some cases there are marked remissions, so 
much so that the friends are deceived into thinking that a re- 
covery is taking place. Patients become very irritable in the 
early stages ; a sudden outbreak of violence may be the first 
indication of aberration. The multitudinous extravagant and 
impracticable business ventures in one formerly astute in these 
matters are often the first indications that lead the friends to 
surmise that the man is insane. Unnecessary purchases may be 
the first signs noticed. 

The memory becomes profoundly impaired, great deficiency 
in regard to time being especially prominent, particularly con- 
cerning recent events. Later, the memory for remote events 
suffers the same impairment. 

The most conspicuous mental changes are noted in the astound- 
ing claims made by the patient. He is a veritable Munchausen 
— stronger than Samson; literally able to move mountains, 
capable of building a bridge to the moon; of reaching to the 
stars; he has a million wives, thousands of children; can create 
a bushel of diamonds a minute — these and other even more 
exaggerated claims of prowess and power being made by one who 
perhaps can scarcely articulate the words, and who is too feeble 
to convey a spoonful of food to his mouth. Although, as a rule, 
when physical disability becomes extreme, grandiose delusions 
are less in evidence, still some patients may be heard to mutter 
something about " millions " when speech is practically unintel- 
ligible. 

Absurd ideas of strength and of grandeur seem less pro- 
nounced in women paretics than in men ; still, their fantastic 
claims, when made at all, do not suffer those of the men to eclipse 
them; their husbands are legion; they have diamonds for 
eyes; their dress is the Cloth of Gold; each tooth is a pearl, 



322 NURSING THE INSANE [Chap. XXV 

and if one should be extracted, they could cause another to spring 
up in its place; they will give you a thousand billion dollars, and 
will be equally munificent to any other person near by. 

Two paretics will occasionally talk together, and each will try 
to outdo the other. Two railroad engineers, occupying neigh- 
boring beds, both cases of paresis, and both, as it happened, 
having the same surname, though not related, boasted as follows : 
One told that he was once making a certain run and ran the engine 
so fast that when she got in she was white-hot, whereupon the 
other told of a run that he made in which he ran so fast on a 
crooked road that the swinging of the engine put the headlight 
out. Then the first narrator told that he had just received a 
present of a ten-story marble palace, and the other followed with 
the statement that he had just received a diamond pin from his 
diamond mines in South Africa. But the other had picked up a 
diamond one foot in diameter on the battle field of the Boer 
War, just after a shell struck at his feet, and although it was 
shattered some, the pieces were so big he was using them yet. 

The startling inaccuracies and discrepancies in the paretic's 
conversation are entirely overlooked by him, showing how pro- 
foundly impaired is his judgment. When you point them out to 
him, he fabricates still more to extricate himself. 

The emotions are very unstable ; the patient is at the mercy of 
any one who plays on them, and can easily be made to laugh or 
cry — a wavering expression, beginning as a smile, often changes 
to one of anxiety or grief, perhaps from so slight a stimulus as 
a frown or a sterner tone on the part of the interlocutor. A 
pathetic optimism is, however, seen in many cases, the patient 
replying that he feels " fine," or " first rate," when the disease 
has already made sad inroads in his physical and mental economy. 

There are four types of cases, named, according to the predomi- 
nating mental symptoms, as the demented, expansive, agitated, 
and depressed types. The demented form is most common. 
This runs a rapid course, as a rule, some cases dying within six 
months, and but few living more than three years. Delusions 
and hallucinations are common. The expansive form is the one 
in which fantastic delusions are so conspicuous. This runs a 
prolonged course, four to fifteen years, and often shows marked 



Chap. XXV] FORMS OF MENTAL DISEASE 323 

remissions. The agitated form is rather sudden in onset, and 
usually terminates in less than two years. It is characterized 
by great motor excitement, grandiose delusions, and clouding of 
consciousness. The depressed form has many hypochondriacal 
and other depressive delusions; there may be clouding of con- 
sciousness and stuporous states. Most of such cases die within 
two years. 

Melancholia. — The term melancholia has of late been re- 
stricted to a form of mental depression occurring during the 
period of involution. The age limits are usually given from forty 
to sixty. This and senile dementia are, therefore, spoken of as 
involution psychoses. There are other cases of depression, how- 
ever, occurring earlier in life than the involution period, that were 
formerly classed as melancholia, and since these resemble the 
involution depressions very closely, they may, for practical pur- 
poses, be considered together. 

Patients with melancholia suffer from profound depression and 
despondency; they are full of morbid fears and hypochondri- 
acal delusions; of remorse for all the misdeeds of their past, 
whether trifling or grave in character. Their mental pain is 
extreme ; they are not only tortured by the ills they have, but 
feel themselves about to be overwhelmed by others that they 
know not of. Some of these cases get well, others drift into 
a condition of chronic depression from which they cannot be 
aroused. 

Persons who develop melancholia have in more than half 
the cases been weighted with a defective heredity. Some shock, 
grief, or unusual strain at this period of susceptibility serves to 
induce the outbreak. 

The distinguishing features of this psychosis are exaggerated 
self -depreciation, despondency, a multitude of fears, delusions of 
a hypochondriacal nature, extreme worry, anxiety, and agitation, 
with perhaps moderate clouding of consciousness, and a tendency 
to dullness of the mental faculties, or to actual deterioration, 
after the disease has lasted for some time. 

The first symptoms are usually those of bodily discomfort, 
headache, dizziness, pains around the heart, palpitation of the 
heart, poor appetite, and general debility. Some difficulty in 



324 NURSING THE INSANE [Chap. XXV 

application is felt, later self -accusations appear; remorse for real 
or fancied misdeeds drives the patient to unending self-castiga- 
tions. Doubtful acts in the past assume immense proportions, 
and the person suffers horribly from fears of on-coming pun- 
ishment, which, however, he says is merited, therefore inevi- 
table. 

Such feel that they have sinned against the Holy Ghost; 
that it is wrong for them to eat, since by their act others must 
starve; that the weight of the world's woe rests on them; that 
the world is coming to an end, or is already at an end; some 
even declare that the earth is annihilated, the sun and stars 
are blotted out, that all creation has returned to darkness and 
chaos; that no one is alive, and that nothing is as it seems; 
that everything they think or say or do, or refrain from thinking, 
saying, or doing, brings fresh woe upon every one about them. 
Some horrible fate awaits them just around the corner; some 
overwhelming calamity is just about to engulf them and all they 
hold most dear. 

The mental pain, nay, agony, of this class of cases is much 
greater than that of other depressions, e.g. that of manic-de- 
pressive insanity. The agitation and anxiety are much more 
pronounced; their self-torture is extreme, and the attempts at 
suicide may be many and persistent. These patients walk the 
floor, tear their hair, wring their hands, chew their nails, mutilate 
their skins, and moan or groan piteously, " I'm lost, I'm lost ! 
what will become of me? " etc. 

As a rule these patients retain consciousness of their environ- 
ment, but their harrowing delusions are so insistent that they can 
harp only on one string — the misery that envelops them body 
and soul. Some cases are marked by even more pronounced fears 
and anxiety, and by actual clouding of consciousness. 

It is often difficult to differentiate between melancholia and 
the depressed form of manic-depressive insanity. One needs 
to bear in mind the anxiety, agitation, and restlessness that 
characterize the melancholiac, and the slowness of thought, 
speech, and action of the manic-depressive patient. 

In cases of melancholia that recover, a gain in weight is usually 
one of the first symptoms noted; the patients sleep better after a 



Chap. XXV] FORMS OF MENTAL DISEASE 325 

time; show less apprehension; say less about their delusions; 
display a show of interest in their surroundings, and usually in 
the course of eighteen months or two years emerge from the 
cloud of blackness that encompassed them. 

Senile Insanity. — Senile dementia is a disease of advanced 
life, as its name implies, occurring most frequently between the 
ages of sixty and seventy-five. It is progressive, leading to com- 
plete dementia and death. The duration may be only a few 
months, or it may last from three to five years. This is the form 
of insanity that the laity probably most frequently have reference 
to when they speak of " softening of the brain' ' — a term that 
has no place in the physician's vocabulary, and which should be 
abandoned because of its vagueness and inaccuracy. 

Heredity, shocks, and acute diseases play their customary 
part in the causation. Some families show a strong tendency to 
senile deterioration. In this, as in most other forms of insanity, 
the exciting cause of some bodily disease, or a shock, simply acts 
as the last straw to break the back of one already heavily 
burdened. 

The varying forms of senile insanity are accompanied by 
hardening of the brain tissue and its blood vessels. Softened 
areas in certain parts are often found. 

With some patients the manifestations of senile changes are 
so slight as to be unimportant, and scarcely to be distinguished 
from physiological senility — weakness of memory, childishness, 
reiteration of the same things, and inability to recall names and 
events of recent date. But when gaps in the memory are made 
good by fabrications; when delusions develop that the person 
is perhaps being purposely annoyed, cheated, robbed; when the 
patient evinces an unaccustomed indifference to the things that 
would formerly have moved him to joy or tears ; when peevish- 
ness, perplexity, discontent, and unrest abound, then it is plainly 
to be seen that a true psychosis is established. The emotions 
become very unstable and shallow; the patient dozes through 
the day, and ransacks the house at night, rummaging aimlessly 
through chests and closets, often scolding and fault-finding, or 
even soundly abusing other members of the family. His former 
good habits in regard to eating, dressing, and attending to his 



NURSING THE INSANE [Chap. XXV 

daily wants are neglected, and the condition is likely to pro- 
gress until the patient becomes an unclean, unkempt, and a most 
pitiable object. 

Aggravated cases have extreme clouding of consciousness; 
they do not know where they are ; beg to be taken home when 
they are at home ; may say they want to go to their mother's, 
and when asked where she is, answer, " In Ireland," and then 
start to walk there. They may fail to recognize the members 
of their family, yet greet as a hail-fellow the total stranger, 
calling him by the name of some friend, perhaps dead many years 
ago. They lose all account of time, cannot even distinguish day 
from night; will tell you that they are twenty-five or thirty, or 
" nearly forty " years of age in the course of one minute's conver- 
sation. Their own age being somewhere in the seventies, they 
will perhaps insist that their father is but fifty — " hale and 
hearty "; and the next minute will recollect that he died years 
ago. They make the most contradictory statements without 
detecting their errors, but when confronted by them usually 
promptly fabricate something which to them is an adequate 
explanation. 

Some of these patients are quick at repartee and evasion; and, 
as though dimly realizing their inability to answer correctly, will 
" hedge " skillfully at the questions propounded. They " can't 
remember just for the minute," they " have an important en- 
gagement to keep and must not be detained," etc. One old 
lady who wandered off the ward, when brought back by the 
physician who found her aimlessly walking on the grounds, said, 
when questioned, that she " was looking for patches to mend 
that black dress." 

Hallucinations of sight and hearing are common, also illusions. 
Every sound refers to the patient, chance passers-by are old 
friends ; voices around her are calling her, and she must go 
and answer the summons. These poor creatures are extremely 
meddlesome and trying in a household. They will undo work 
that has been done, and pull beds to pieces to look for something 
that they are unable to name, even if they knew what it was when 
they started. They will putter with the fires, put sugar for salt 
in food, collect broom splints and other worthless objects and 



Chap. XXV] POEMS OF MENTAL DISEASE 327 

hoard them in all sorts of places, eat soap, or other harmful 
and disgusting things, put on several sets of underwear, put their 
feet in their nightgown sleeves when trying to dress, and in 
countless ways demonstrate their utter confusion and inability 
to care for themselves, at the same time that they show the most 
stubborn resistance to being cared for by others. 

By reason of their restlessness they become tremulous and 
exhausted. It is difficult to get their attention long enough 
to make them take sufficient nourishment, so intent are they 
in doing they know not what, and in going they know not where 
— the urgency for doing and going being the main thing. 

There are all grades of senile dementia, from simple dotage to 
that of the delirious form, in which latter the patient suffers 
from imaginary sights and sounds, and from the false beliefs 
that result from these distressing symptoms. 

The course of the disease is toward progressive deterioration. 
Apoplectic seizures may close the career; sometimes these 
are accompanied by hemiplegia, sometimes not. Milder cases 
should be cared for by the friends, but patients who become 
unmanageable, and sources of continual annoyance to the entire 
household, are properly committed to the State hospitals. 



CHAPTER XXVI 

forms of mental disease (Continued) 

Manic-depressive Insanity. — Manic-depressive insanity is the 
name given to a mental disease which recurs in definite forms, 
periodically, throughout the life of the individual, a typical 
case showing excited and depressed stages with normal periods 
between, and with little or no tendency to mental deterioration. 
It is the disease that was formerly spoken of as acute mania, 
the excited stage usually giving the name to the disorder, and 
the depressed stages slipping by as a rule without much account 
being taken of them; or, when noted, being considered as an 
entirely different disease, melancholia; or, if the excitement and 
depression, with a lucid period between, were so well marked in 
any one case as to compel them to be regarded as a distinct 
cycle, the disease was called circular insanity. These terms 
have now pretty generally given place to the term manic-depres- 
sive insanity, as this covers both phases of what is now con- 
sidered one disease-process. 

Typical cases of manic-depressive insanity present at some 
time in their career fairly well-marked phases of maniacal excite- 
ment, and again equally well-marked ones of morbid depression, 
with normal behavior between. But there are many cases where 
only the maniacal phases recur from time to time,, and others 
where the depressed forms only are seen, and still others where 
a mixture of the two phases may be seen in one individual, in a 
single attack. 

In the maniacal type there is great excitability and loquacity; 
mental and physical restlessness abound, with rapidly changing 
emotions; perhaps later, rambling, disjointed talk, rhyming, 
shouting, mischievousness, violence, disorder, and destructive- 
ness. 



Chap. XXVI] FORMS OF MENTAL DISEASE 329 

In the depressed type the patient is dejected, undecided, and 
inactive, slow in speech and thought, with a tendency to become 
more and more sluggish in his mental and physical life, and often 
to develop delusions and hallucinations of a distressing character, 
and to show some clouding of consciousness. There are various 
degrees of the maniacal form. The mildest ones are called hypo- 
mania, more pronounced ones mania, and the most extreme 
are called delirious mania. 

Patients with hypomania attract attention in their families 
by their almost ceaseless activity; they are regular chatterboxes; 
they are up early mornings stirring up things generally; they 
contrive to be very busy over the least little thing, and delight 
in getting into first one thing, then another, abandoning each 
as soon as they tire of it whether it is completed or not. Some 
develop great activity in letter writing, others in visiting their 
friends. The friends comment on how well they are looking and 
what good company they are, often without a suspicion that 
this increased activity and vivacity are the result of a mor- 
bidly excited nervous system. The handwriting usually shows 
exaggerated traits; it is executed rapidly with strong, bold 
strokes, much underlining and flourishing, and often with other 
ornamentation. If the excitement passes beyond the point 
described, the patient may show much exaggeration in voice, 
speech, manner, and dress, may affect bright colors, flowers, 
and perfumes, such manifestations perhaps being foreign to him 
in his normal state. In their talk, and especially in their letters, 
these patients change the subject frequently and abruptly, fail to 
finish various subjects that they start, and easily get switched off 
to talking on any subject that is suggested by what is happening 
around them. Self-esteem is prominent in these patients, and 
their own point of view, their own desires and projects are the 
only ones that they tolerate. They are the prey to their impulses, 
and while the mood is commonly cheerful and even exuberant, 
they become irritated on the slightest provocation, and are prone 
to indulge in detailed complaints and in angry and abusive 
talk. These attacks last from several weeks or months to a year 
or more, the patient gradually becoming normal just as he 
gradually became excited. 



330 NURSING THE INSANE [Chap. XXVI 

In the distinctly maniacal condition the patient presents more 
striking manifestations than in hypomania. His great excit- 
ability is shown in brilliant eyes, rapidly changing facial expres- 
sion, smiles, winks, grimaces, ill-timed playfulness, boisterous- 
ness, and exaltation. His feeling of well-being is very pro- 
nounced, his mental and physical activities are very great. The 
sense of fatigue seems lost. He is constantly on the go, shows 
abnormal quickness of vision and hearing, but indifference to 
heat and cold, to hunger and pain. He is capricious in the 
extreme, yields to every impulse as does the hypomaniacal 
patient, but impulses are yielded to in quicker succession, making 
a jumbled emotional reaction. He may be witty, playful, jolly, 
and hilarious, but is as likely to be irritable, domineering, and 
violent. His outbreaks are usually short-lived. He is full of 
mischief, delights in playing pranks and in destroying things 
just for the sake of seeing the havoc he can make; he keeps his 
dress and hair in disorder, often decorates his person fantastically; 
is likely to be indecent in talk and behavior, and is given to 
showing the worst conduct before the opposite sex. At first, 
though talking excitedly, he may be able to keep to the point ; 
but as the disease progresses, he is unable to hold to the topic 
of conversation ; his mind wanders in the track of least resistance ; 
so slight a thing as the jingling of keys, or the sight of a watch, 
will serve to distract him so that he weaves some reference to 
these things into his talk and is the prey of the countless impres- 
sions and sensations that come to him. This is called distrac- 
tihility. The patient has lost his power of inhibition, and shows 
a tendency to act upon every impulse and idea that comes to 
him. Everything seems of equal importance, so he tries to 
comment on all of them, and as a result can make no coherent 
comments on any. One sound suggests a similar sound; he 
makes rhymes, puns, and revels in many word associations ; he 
sings, dances, shouts, exposes his person, tears his clothes, 
destroys property, and grows more and more incapable of 
grasping and answering questions addressed to him — chiefly 
owing to the multitude of ideas that crowd his consciousness 
and efface each other before any of them can be expressed. 
Even when the case is not so extreme, and the patient is still 



Chap. XXVI] FOKMS OF MENTAL DISEASE 331 

able to answer rationally and connectedly, there is a great incli- 
nation to trifle and to give consciously incorrect and " smart " 
answers, and to call persons by wrong names. Hallucinations 
and delusions are not common, although they may appear 
to be to a casual observer because the patient is so prone to 
make absurd boasts and exaggerated statements. Vague hal- 
lucinations of a very fleeting character may be present ; illusions 
due to fluctuating attention are frequently noted. The faces 
and voices of strangers are interpreted as belonging to the 
friends at home. Some patients develop persecutory delusions 
for a time, which disappear ordinarily as the case clears up. 

The physical symptoms are as follows : the pulse rate is 
usually quickened in proportion as the motor restlessness in- 
creases, and, as a rule, the blood pressure is low during excited 
periods, and the respiration accelerated but shallow. Marked 
variations in temperature are not established as being directly 
due to the excited state. The bodily weight nearly always 
decreases during maniacal periods. The pupils are usually 
widely dilated and react to light ; the deep and superficial reflexes 
are generally increased. Digestive disturbances may be present. 
Many patients bolt their food, consuming enormous quantities 
(bulimia) ; others are too busy with their talk and their ceaseless 
motions to stop long enough to eat. The secretion of saliva 
is often increased, and during the height of attacks patients 
expectorate large quantities, taking malicious delight in defacing 
the walls, soiling the bedding, and using the faces of attendants 
as targets. Sleep is deficient, insomnia often extending over 
long periods without signs of exhaustion. 

Manic cases are the ones that people in general are ready to 
admit are insane; this seems to be the condition that stands for 
insanity in the lay mind; the laity has great difficulty in recog- 
nizing more controlled forms as insanity. Many also refuse to 
consider hypomaniacal types as actually insane, simply because 
the patients have enough power to inhibit their talk and acts 
so as to keep fairly within bounds. Such eccentricities and 
annoyances as result from their abnormal condition are set down 
to meanness, malice, and total depravity, instead of being chari- 
tably judged as the manifestations of an abnormal mentality. 



332 NURSING THE INSANE [Chap. XXVI 

The evidence of a certain shrewdness common to such patients 
is seen, and it is wrongly concluded that because the person 
shows method in his madness he is not really mad, but only mean. 

A defective heredity is responsible for the larger number of 
these cases. This form of mental disease often attacks persons 
who, though they may have been considered eccentric, because 
of temperamental instability, have been rather above the average 
in brightness and cleverness. Women between twenty and 
twenty-five years of age, predisposed to manic attacks, usually 
succumb suddenly after some bodily disease or mental shock, 
or later, during pregnancy, or at the time of, or soon after 
confinement. 

Improvement, when it once starts, is usually rapid; the patient 
often recovers without recollecting what took place during the 
height of the attack. Others seem to remember well most of 
the happenings and experiences, but are loath to discuss them, 
being ashamed of what they remember to have said and done 
when unable to exercise self-control. Subsequent attacks may 
follow rapidly, or there may be intervals of several years between 
seizures, or, as has been said, a depressed attack may occur, 
and may alternate with the kind above described. 

There remains to be described the delirious form of the ma- 
niacal type before considering the depressed form. Delirious 
mania, as has been said, is the gravest of the forms in the ma- 
niacal group. Here the consciousness is greatly clouded, the 
bodily and mental restlessness are intense, the speech is inco- 
herent; distractibility is more pronounced even than in the 
preceding form; hallucinations of all the senses are numerous; 
changing delusions are prominent, and a dreamy, delirious con- 
dition supervenes. The patient rapidly shows the effects of 
intense excitement; nutrition becomes greatly reduced; a gen- 
eral tremulousness is seen; sleeplessness is persistent; the face 
becomes congested; the eyes are red, injected, and dull; the 
pulse becomes rapid and weak; perspiration is profuse. This 
form runs a rapid course, the height of the attack being reached 
usually within fourteen days, and the symptoms gradually dis- 
appearing in the course of a few weeks. If exhaustion or infec- 
tion enter into the case, the termination is likely to prove fatal. 



Chap. XXVI] FORMS OF MENTAL DISEASE 333 

The depressed form of manic-depressive insanity usually comes 
on gradually. Patients begin by losing interest in their sur- 
roundings; they cannot apply themselves as usual to routine 
work; they find difficulty in keeping the run of conversation, 
or in keeping their thoughts on what they read, because the 
association of ideas is retarded. As the disease progresses, they 
show still more incapacity, indecision, inactivity. They have 
ups and downs, some days feeling like themselves, but gradually 
drifting into a sluggish, dejected, apathetic state, yet, as a rule, 
conscious of all that is going on around them. They sit with 
bowed heads and folded hands. When attempts are made to 
rouse them to activity, they seem powerless to exert enough 
decision to comply. u I can't, I'm so nervous," is the burden 
of their cry as they relapse into a listless, dejected condi- 
tion. Constraint is a more prominent symptom than depression 
with these patients. They hesitate in walking and in speaking, 
sometimes merely moving the lips when questioned, as though 
trying to speak, but unable to do it. They look at everything 
through blue glasses, and if they voice their complaints, it is 
seen that they worry over the past and the future; they think 
that they are coming to want or to some dreadful torture. They 
are tired of life, and say so, but as a rule do not often actu- 
ally attempt suicide. They usually recognize that they are 
mentally ill. 

It is difficult for these patients to answer questions, to start 
to do the simplest act, or to think out the simplest thing. They 
are what we call retarded. They reply in a low voice, if at all, 
and usually in monosyllables. 

Sometimes very depressing delusions arise: they think they 
are in the last stages of some disease, or that their stomachs 
are closed up ; that they can never die ; that their souls are lost ; 
that the world is all gone; that their whole life has been one 
colossal mistake, and that they are bringing disease and ruin 
on all about them. Hallucinations are also common in this form, 
and are entirely depressive in character. 

There may be a clouding of consciousness, partial with some, 
profound with others. Or there may be a torpor, a kind of 
dream-state, the result of extreme self-absorption, but from 



334 NURSING THE INSANE [Chap. XXVI 

which they can be momentarily aroused. Others sink into a 
stupor, in which they lie in bed, scarcely responding to any exter- 
nal stimuli, but showing on their countenances an expression of 
fear, and in their passive resistance and peculiar attitudes the 
presence of morbid anxiety. 

The physical complaints are usually of numbness in the head, 
oppression of the chest, and palpitation of the heart. The 
pulse is slow; the blood pressure usually rises. The appetite is 
poor, and the digestive and excretory processes are sluggish. 
Sleep is broken and unrefreshing, and often disturbed by anxious 
dreams. The handwriting is faint and tremulous, cramped and 
shrinking in character. 

The stuporous form shows a deepening of all the conditions till 
the patient experiences marked clouding of consciousness. Nor- 
mal stimuli are not apprehended, and he becomes the victim 
of dream-like delusions. He feels himself in another world; 
all is changed; some terrible fate is impending. Hallucinations 
often persist after improvement has set in. The duration of 
the most critical symptoms is generally a few weeks ; the entire 
depression usually lasts several months. 

As in the manic phase, these cases tend to recovery, but also 
to a recurrence of attacks of one or the other form. Some, instead 
of showing any except the briefest period of sanity, pass directly 
from one attack into another. Improvement is usually gradual. 

These patients enlist one's sympathy to an unusual degree 
since, during their lucid intervals, they are so rational, and so 
keenly alive to their condition, knowing as they do after several 
recurrences that fate has a sword of Damocles swung over their 
heads, and that, try as they will, they must needs succumb to 
recurring outbreaks. 

Between attacks much can be done to ward off succeeding 
ones by so regulating the patient's life, occupation, and environ- 
ment that excitement and strain are reduced to a minimum. 
Everything contributing to bodily and mental stress should be 
avoided as far as possible. Out-of-door life in the country is 
the one most to be desired. Especially is it important that 
plenty of sleep is regularly secured. Hurry, worry, ambitious 
undertakings, indulgence in stimulants, things that reduce the 



Chap. XXVI] FORMS OF MENTAL DISEASE 335 

bodily tone and harmony — all these are fruitful causes of 
recurrences. Wise supervision of the patient should be main- 
tained by some competent person without the patient realizing 
that it is being done. 

Paranoia. — Paranoia is one of the terms that has been a 
special bone of contention among students of psychiatry, some 
authorities compassing certain things in their use of the term, 
and others certain others of a diverse nature. 

All that is attempted here is a description of what is most 
generally conceded to be meant by the use of the term. 

The word, then, is usually applied to a mental disturbance 
which manifests itself mostly in early adult life ; which is usually 
progressive, and when typical is characterized by a well-defined 
system of persecutory delusions. As a rule it is seen in persons 
who are bright and clever, but have perhaps been narrow-minded 
and always considered a little " queer." 

A study of the history of the patients who develop paranoia, 
or paranoid conditions, often reveals that some have been almost 
geniuses along certain lines. They show unusual association 
of ideas, see things in new and strange relations — an ability 
that in a genius enables him to profit by his vision, but in these 
persons too often comes to naught, from lack of power to make 
the new thoughts useful. Some of these persons are capable of 
inventions; sometimes they can make suggestions that more 
efficient doers can carry out ; but as a rule most of their philoso- 
phizing consists in advancing impractical schemes for the further- 
ance of the welfare of a class or a race. From individuals of 
this class, according to their varying capabilities, we get invent- 
ors, busybodies, reformers, revolutionists, founders of new sects, 
cranks, and paranoiacs. Paranoia develops when the new ideas 
assume such one-sidedness and fixedness as to dominate the 
whole personality. 

Persons with paranoia are the ones it is often so difficult for 
the laity to believe are insane, simply because consciousness 
remains unclouded, behavior correct as a rule, and the patients 
retain many of their mental faculties unimpaired. They often 
show remarkable ability in some one line ; their powers of rea- 
soning are excellent, but in regard to their own false beliefs 



336 NUKSING THE INSANE [Chap. XXVI 

reason is all astray because they start from a false premise. 
These patients usually consider themselves underrated geniuses. 
Extreme self-satisfaction is a striking feature in this form of 
insanity. 

Early in this disease the patients become distrustful, and every 
trifling oversight on the part of friends is regarded as an inten- 
tional slight. Self-love is wounded at every turn, and the atti- 
tude of suspicion so characteristic of these patients begets con- 
tinued unhappiness ; trifles light as air become weighty proofs 
to them that they are objects of some special spite or scheme. 
Hallucinations, especially of hearing, may develop and confirm 
their suspicions. They may hear insulting voices calling them 
names, or accusing them of immoral conduct. 

At first the wretched person quits his place of work under the 
belief that his associates taunt him, spy on all his acts, and are 
in league to drive him from their midst. A new field of labor 
is undertaken, and for a time all goes well; the suspicious atti- 
tude, however, is maintained, and it is not long before the same 
difficulties are experienced anew. He leaves and tries another 
place, and another, with the same result. He comes gradually 
to believe that all these persons have been conspiring to annoy 
and persecute him. He suffers intensely from the accusing 
voices that molest him. Chance items in the newspaper seem 
to bear some hidden reference to him; overheard comments of 
friends or strangers are wrongly interpreted as referring to him. 

The feeling of self-importance that usually accompanies pa- 
tients thus afflicted is in some instances carried to the extent 
of the patient's believing that he is the special object of Divine 
guidance, and that Providence has in view some secret mission 
for him to perform, hence the persecution to which he must 
submit. Another believes that he is a great personage incog- 
nito, that he was perhaps stolen in infancy from some royal 
household, and has been brought up in obscurity, and subjected 
to trials that will some day come to an end, and his vindication 
be triumphantly established. Whatever false beliefs develop, 
they are persistently held, and are finally woven into a plausible 
system. When these delusions are attacked, they are ably 
defended by the patient, whose reasoning is often startlingly 
clear and cogent, but, as before mentioned, on a false basis. 



Chap. XXVI] FORMS OF MENTAL DISEASE 337 

Some of these patients' delusions center about religious topics, 
others about sexual matters, political questions, etc., and their 
conversation and conduct are colored according to whatever 
subject engrosses the mind. 

As a rule, patients may have this disease for years without 
showing impairment of memory or of the judgment (except 
in the field of their delusions), and many of them continue to 
take an interest in current events, literature, art, etc., showing 
their wonted discrimination and acumen. 

It is to this class of the insane that " cranks " belong. As a 
rule, persons suffering from paranoia should be safeguarded in 
some institution, since the nature of their delusions is such, 
and their tenacity in holding them so great that, unless pre- 
vented, they feel bound to act in accordance with their false 
beliefs. Such acts often result in the destruction of the life 
or the property of whomsoever their delusions center about. 
Such persons so firmly believe that they are the victims of plots 
and schemes, that they easily justify themselves for avenging 
their wrongs, often even boasting that they are fulfilling God's 
commands. 

Persons suffering from this form of insanity may have remis- 
sions of long or short duration, but it is one of the least hopeful 
of the psychoses. 

Epileptic Insanity. — Epileptic insanity is a condition which 
sometimes accompanies the nervous disease, epilepsy, or " falling 
sickness," as it used to be called. 

Epileptic seizures are mostly of two kinds, grand mal and petit 
mal, but there is a form called Jacksonian epilepsy; and there 
are outbreaks of violence, and dreamy states of longer duration 
than those of petit mal that are regarded as epileptic equivalents. 

In grand mal, or greater epilepsy, there may be a warning — 
a something which the patient senses and which gives him a 
premonition of the attack. This is called the aura. It may 
be a numbness in some part, a tingling, a vague discomfort, or 
actual pain ; it may be tremor, dizziness, nausea, or a gnawing 
feeling at the pit of the stomach, or a burning; or he may feel a 
sensation like a ball rising in the throat; may see flashes of light, 
colors, or animals before his eyes, or actual objects may appear 



338 NURSING THE INSANE [Chap. XXVI 

greatly magnified to him, or transitory blindness may be expe- 
rienced. The disturbance may be in the sense of hearing — 
buzzing, roaring, ringing, and whistling may be heard; or he 
may smell disagreeable odors ; or taste sweetish, bitter, or other 
tastes which have no objective reality. Or the aura may be 
psychic in its nature, and the patient be suddenly overcome 
with an indefinable fear, or may experience an indescribable 
sense of freedom and well-being. Still other aurse may show 
themselves in strange movements: the patient may start up 
and run rapidly a long distance, then fall in the convulsion. 
The aura, whatever its nature, is usually followed by a cry, 
then the person falls and becomes unconscious, as a rule, and 
convulsive movements in certain parts are later followed by 
general convulsive movements. The convulsive symptoms them- 
selves barely last two minutes. The patient may become con- 
scious almost immediately on their cessation, or unconsciousness 
may last for several hours. 

There may be no aura and no cry ; the fall may come without 
warning, and the convulsive movements are then usually observed 
first in a hand or a leg, but they may begin in almost any part 
of the body. The eyes roll up, the pupils dilate, the conjunctivae 
show congestion, and the face gets swollen, blue, or livid ; the 
reflexes are lost; the tonic and clonic convulsions are followed 
usually by stertorous breathing and by coma. The patient 
usually bites his tongue and froths at the mouth ; there may be 
involuntary urination. The thumbs are more often than not 
placed between the index and second fingers. Sometimes in 
coming out of a convulsion, instead of sleeping, patients begin 
groping around on the floor as if in search of something. They 
are frequently observed to smack the lips during a seizure. 
Some show a tendency to fall in just the same way each time. 
In such cases the parts of the body liable to injury may be 
protected by pads worn for this purpose. 

In petit mal there is a momentary loss of consciousness of a 
few seconds only, with or without slight convulsive movements. 

In Jacksonian epilepsy the convulsive movements are confined 
to one part, e.g. an arm or a leg, or to one group of muscles. 
Consciousness is not lost as a rule, and the patient seldom falls. 



Chap. XXVI] FORMS OF MENTAL DISEASE 

In the dreamy states, or psychic epilepsy, there are no con- 
vulsive movements ; there is merely a temporary blank in the 
consciousness, and when the patient comes to himself he has 
no memory of what transpired during the attack. This dreamy 
condition may last only a few seconds, or may extend over days 
and weeks. 

The condition called status epilepticus is where attacks fol- 
low one another very rapidly, only a few minutes apart ; they 
may be numbered by the hundreds ; coma and exhaustion are 
continuous between the seizures ; the pulse, temperature, and 
respiration are greatly increased, and the patient's condition 
is extremely critical. 

A defective heredity is one of the most frequent causes 
of epilepsy. Alcohol is perhaps the next most frequent. 
A certain number of cases are directly traced to head in- 
juries. Many cases of epilepsy develop in infancy or child- 
hood, others come on in adolescence, and still others in ad- 
vanced life. 

Epileptics often present certain physical stigmata; their 
heads may be unnaturally large, or undersized. They often have 
what is called the epileptic physiognomy — a broad forehead, 
broad and flattened nose, protruding upper jaw, thick, coarse 
lips, staring eyes. Their teeth are often badly placed, their 
ears misshapen and outstanding. A case of long standing is 
likely to present numerous scars from cuts and burns, especially 
on the face and head, and if bromides have been given a great 
deal, there is likely to be seen the bromide acne. If much dete- 
rioration is present, the countenance is heavy and dull, or it may 
present a fatuous amiability. 

In speech, the epileptic often shows marked disturbance. It 
may be abrupt, emphatic, impudent, jerky, or drawling. 

When, as a result of epilepsy, a real mental disorder develops, 
we note impairment of intelligence and of memory to a greater or 
lesser degree, incapacity for effective mental work, marked emo- 
tional instability, lack of inhibitory power, and a weak and 
forceless moral sense. Persons so afflicted may be subject 
to periodical outbreaks of anger and violence, and to dreamy 
states in which there is partial clouding of consciousness. In 



340 NURSING THE INSANE [Chap. XXVI 

this state grave misdeeds may be perpetrated without a vestige 
of remembrance of them. 

Periods of anger may precede or follow convulsions, or may 
occur independently. Sometimes days before the attack the 
patient is noticed to become talkative, fussy, and extremely 
fault-finding, harping on trifles that he would disregard any other 
time; his sleep may be disturbed also, and he may complain 
of headache, or may have all manner of trivial complaints for 
which he demands relief. He may make dangerous attacks 
upon others at these times, or may destroy clothing and property. 
Some patients are overtaken with a kind of furor that knows 
no bounds : some of them will run violently down the hall, and 
woe to any one or anything that gets in their way. They will 
strike or run down a living obstacle or demolish an inanimate 
object in a blind, unreasoning rage. Sometimes they will curse 
nurses and physicians in a blood-curdling way, yet these same 
patients, when not suffering from paroxysms, are often very 
kind and helpful, especially to fellow-patients, running to their 
aid when they, in turn, are taken with seizures, and showing 
considerable ability in dealing with the situation in a routine 
way. 

Epileptics who are insane are weak in mind and morals. 
Their emotions are shallow. They can be trained to routine 
tasks, but their power of attention is of limited range and easily 
diverted. They are prone to read the Bible and to pray a good 
deal, and not infrequently are heard to speak familiarly of God as 
a sort of boon companion. One little epileptic, on being asked 
by the nurse if she was not going to say her prayers, said, " Oh, 
I forgot ! " jumped out of bed, fell on her knees, hurriedly 
said, " Good night, God," and jumped back again. Another 
epileptic, who is much given to profanity before seizures, will 
at other times pore over her Bible, and ostentatiously inform 
every one that she is reading the Holy Scriptures. 

Epileptics are tiresome in manner and conversation. They 
frequently request private interviews with a great show of some- 
thing important to communicate, and with the intimation that 
secrecy is imperative, yet when given a hearing, it is usually 
found that they merely wish to tell you that they are getting 



Chap. XXVI] FORMS OF MENTAL DISEASE 341 

better every day, that they wish to go home ; or sometimes they 
will give you a circumstantial account of some unimportant 
happening on the ward. Their memory and judgment are 
greatly impaired. They often make big plans and boast of what 
they are going to do, failing to appreciate their limitations; 
others, less deteriorated, are aware of their limitations, and chafe 
under their inability to undertake or to accomplish much outside 
of a very limited range. Where deterioration is conspicuous, be- 
havior is often silly in the extreme ; yet even these patients can 
be trained to become excellent helpers on the wards, and many 
of them are dependable, except when suffering from sulkiness 
or irritability, or from the actual attacks which overtake them 
from time to time. Illusions are sometimes noted after convul- 
sions. Hallucinations and delusions are rare. 

The prognosis in this form of insanity is unfavorable in the 
extreme. 

Hysterical Insanity. — Hysterical insanity is a form of mental 
aberration characterized by very changeable emotions, weakened 
will power, and exaggerated self-consciousness, and with these 
there may appear from time to time certain attacks which 
present a variety of mental and physical symptoms, including 
dreamy states, numbness, and other abnormal sensations, paraly- 
ses, convulsions, blindness in one or both eyes, taste and smell 
defects, and the like. These symptoms are believed to be the 
outcome of morbid ideas and emotions. 

Persons who develop hysteria are usually hampered by a 
defective heredity, as well as by their own morbid constitution. 
Defective training and lack of self-discipline, especially in the 
emotional field, are important factors. 

Hysteria is by no means confined to the female sex ; still it 
is more prevalent in girls and women than in men. 

Patients with hysterical insanity show no disturbances in the 
field of consciousness except during their paroxysms or crises. 
They are keenly observant, often bright and vivacious, and may 
show exceptional talent in some field. They crave excitement, 
novelty, and the sensational. As a rule, the desire to attract 
attention and sympathy is so great that the patient will, per- 
haps half unconsciously, exaggerate and even invent symptoms. 



342 NURSING THE INSANE [Chap. XXVI 

They are fertile in arranging situations that will create a sen- 
sation. Some fabricate easily, if the truth cannot be made 
startling enough. 

The most profound disturbance with these cases is in the emo- 
tional field. The patients are unduly excitable, their responses 
to everything are too keen, their sensations too easily aroused, 
and they give way to emotional outbreaks often on the slightest 
provocation. They are far too easily influenced by environment, 
and become unduly enthusiastic over any cause they espouse. 
Their enthusiasm leads them into all sorts of headlong acts; 
their obstinacy is extreme, and their regard for the point of view 
of others is entirely swallowed up in their own way of looking 
at a given thing and dealing with it. 

Hysterics are very uncertain elements in the family life; 
self-absorbed and selfish, everything must bend to their feelings 
and their views. If the self-feeling takes a hypochondriacal 
turn, as it often does, the whole household is kept busy minister- 
ing to their slightest feeling of discomfort, which is dwelt upon 
and exaggerated till the patient grows to believe herself to be 
suffering cruelly. 

If not enough attention is given to such patients to satisfy 
their self-love, they often make threats and sensational attempts 
at suicide for the purpose of impressing friends with the gravity 
of their condition. Because of the instability of the emotions, 
conduct becomes very wayward and erratic. In conversation 
everything is exaggerated with tiresome repetition. The super- 
lative degree is called into use at every turn. These patients 
have little power of application as a rule, and are always talking 
of how tired and weak they are; yet they will spend hours in 
pottering about, and give infinite thought and time to trifles 
that ought to be disposed of summarily. 

All hysterics are not alike, though certain traits are pretty 
common in all; the personality colors the general picture every 
time. 

In the physical sphere symptoms may be very varied ; there 
may be twitchings, contractures, paralysis of perhaps one arm 
or leg, loss of voice, numb areas, or areas of heightened sensi- 
bility, blindness, a ball rising in the throat (globus hystericus). 



Chap. XXVI] FORMS OF MENTAL DISEASE 343 

a piercing nail-like pain through the head, fainting fits, con- 
vulsions, and so on. 

Persons afflicted with this disease may try to starve themselves, 
may refuse to walk or speak for years, may mutilate themselves, 
even torture themselves in order to produce strange or puzzling 
symptoms. Because of these morbid acts on their part, they 
arouse the scorn of on-lookers who fail to realize that such con- 
duct and such feigning are in themselves proof positive of a 
deranged mentality. 

The dreamy states that are experienced in some of these 
hysterical cases may be of short or long duration, and may or 
may not be accompanied by convulsions. It is sometimes 
difficult to distinguish them from epilepsy. Sometimes the 
patients appear to sleep quietly for long periods, and on awaking 
to have no recollection of the extended loss of consciousness. 
Sometimes the patient goes about in these dream-states, per- 
forming various acts with little or no recollection of them on 
returning to consciousness. In other cases, she appears to see 
visions, to hear beatific music, or to undergo most frightful 
experiences, or pleasurable ones — acting the while in the char- 
acter of imagined experiences, regardless of all efforts of the 
bystanders to " bring her to her senses." Some grow extremely 
fantastic or silly or sentimental in behavior, laugh and cry 
uproariously, scream, sing, shout, bite others, or themselves, 
bark like dogs, or mew like cats; and often these tantrums 
end in a short convulsive seizure, after which the patient comes 
to herself and appears mildly depressed, but unaware of what 
took place in the hysteric episode. 

There are cases where the patient seems possessed of two or 
more personalities, so that in one state she seems conscious of 
certain experiences, and lives up to a certain character, while 
in another state she seems an entirely different being, with little 
or no recollection of the feelings, thoughts, and experiences that 
came to her in the first-named consciousness. 

The mind seems to split up into two or more consciousnesses, 
because the person is too nervously weak to hold it together. 
Certain patches, as it were, of the consciousness seem to become 
submerged at times, and so become a part of the subconscious 



344 NURSING THE INSANE [Chap. XXVI 

existence. During grave hysterical episodes these subconscious 
patches may become uppermost, while the usual upper con- 
sciousness is temporarily submerged. 

Patients with hysteria may be afflicted for years. Remark- 
able cures have been effected through hypnotism by getting 
at the subconscious undercurrents that have been at work, per- 
haps for years ; and also by bringing about sound physical health 
and mental hygiene. 

Acquired Neurasthenia. — Acquired neurasthenia, or nervous 
prostration, the so-called "Americanitis," is one of the func- 
tional nervous disorders that demands brief consideration. It 
is not, so far as known, dependent upon actual cell changes, 
but its presence is known by its morbid manifestations. It is a 
disease which attacks the over-employed, the brain worker par- 
ticularly, who is subjected to prolonged mental application 
combined with worry and responsibility. 

Its manifestations are not very different from the congenital 
form of neurasthenia described below. 

Persons suffering from nervous exhaustion are popularly 
spoken of as "nervous." What is it to be nervous? Used in 
this sense, it means to have exaggerated sensibility, exaggerated 
fatigability, and exaggerated emotionalism. " Nervous " per- 
sons can't meet the ordinary ills of life with a normal degree of 
fortitude; they grow discouraged with the smallest failures, 
magnify every obstacle and profess inability to surmount it; 
create painful emotions by representing to their minds ideas 
of danger, of evil, of fear. Instead of opening a telegram and 
finding out its contents, they fear and tremble and conjure up 
all the terrible things it might be, and put the worst possible 
construction upon everything. They seem incapable of looking 
at a question calmly ; we say of them that they make mountains 
out of molehills, then toilingly climb these self-created moun- 
tains, when a wholesome faith and a sturdy common sense 
would remove mountains ; or, perhaps it is better to say, a clear- 
eyed reason would discover that the mountain needs no removal, 
being only a molehill. 

Constitutional Psychopathic States. — There are certain condi- 
tions called constitutional psychopathic states that demand a 



Chap. XXVI] FORMS OF MENTAL DISEASE 345 

few words before leaving the subject of the forms of mental 
disease. Congenital neurasthenia and compulsive and impul- 
sive insanity are the ones we shall briefly consider. 

Congenital Neurasthenia. — Congenital neurasthenia is a con- 
dition of nervous prostration ingrained in the person. Such are 
literally "born tired/' are easily depressed, and prone to inde- 
cision, yet show no disturbance in the field of consciousness 
nor in the intellectual field, so that it seems strange to a 
casual observer to class them with the insane. Continued appli- 
cation in these persons causes an undue sense of fatigue, head- 
ache, and sleepiness. They become hypochondriacal and self- 
centered. They are easily turned aside from their work. The 
power of attention is very poor. Such persons are easily balked 
in any undertaking. They are the prey to morbid fears. If they 
have a sore throat, it is going to be diphtheria; if the nosebleed, 
they fear a fatal hemorrhage. They cross innumerable bridges 
that they never come to, and die a thousand deaths while con- 
juring up others to die of. Slight troubles and indispositions 
affect them seriously, and grave ones often cause profound de- 
pression. In action they are usually precise and constrained. 
The disease may extend over a whole lifetime, with periods of 
comparative comfort between. 

Compulsive Insanity. — Compulsive insanity is a morbid condi- 
tion in which the intellect continues undisturbed, but the patient 
is dominated by compulsive ideas and fears which force them- 
selves upon him against his will, seriously interfering with thought 
and action. These may be indifferent ideas or intensely disa- 
greeable ones. This condition is only an exaggeration of what 
we all experience from time to time in perhaps trying to recall 
a forgotten name; although we keep saying to ourselves that 
we will dismiss it from the mind, the effort to recall it keeps 
cropping up in spite of ourselves. 

Sometimes the compulsive ideas are very absurd, and the 
patient recognizes them as such, nevertheless is dominated by 
them. 

The various fears or phobias come under this head — fear of 
dirt, of contamination, of phthisis, or of other diseases, of open 
places, of the dark, of crowds, and the like. Patients suffering 



346 NUKSING THE INSANE [Chap. XXVI 

from these compulsive ideas will wash themselves by the hour, 
if fear of contamination is the particular obsession; they will 
face death almost as soon as go to a church or to the theater, if 
it is the fear of crowds that dominates them. Others are afraid 
of committing some crime, and take all sorts of absurd precau- 
tions to assure themselves that they have not committed it. 

These patients can comment intelligently about their fears, 
and realize their absurdity, but are powerless to rise above them. 
They may be capable of concealing the fear before strangers 
for a short time, but if one takes away their means of reassuring 
themselves (for example, locks them out of the bathroom and 
prevents the frequent washing, if mysophobia happens to be the 
morbid fear), these patients will develop a restless, agitated 
condition distressing to witness. 

Some psychasthenics, as some of these persons are called, are 
forever asking and trying to answer questions to themselves, some 
of which are absurd, some metaphysical. It is with them as 
though the "why" of childhood were carried on to adolescence 
and maturity. Some persons always remain adolescent of soul. 
Certain ones of this type will query, "Why is the grass green?" 
"Why does c-a-t spell cat?" Some will debate with themselves 
as to whether, if they had pursued a certain course, the result 
would have been this way or that way; some dwell long on why 
God made the world, what is the purpose of evil, and so on ; 
the broader the education, the more inclined are these persons 
to mental rumination on metaphysical questions. They chew 
the cud of these thoughts over and over as a cow chews her cud. 
They are prone to silly scruples and perhaps to abnormal states 
of exaltation and mystic delirium. Some waste a good deal of 
time putting things to rights, working out problems, repeating 
numbers, counting how many times they do a certain thing, etc., 
all of which are signs of mental fatigue. Some are very hypo- 
chondriacal, and are always diagnosing their troubles; some are 
excessively shy. 

These persons often show facial tics, exaggerated reflexes, 
skin-writing, very changeable pupils, anemia, and palpitation. 

Impulsive Insanity. — Impulsive insanity is similar in some 
respects to compulsive insanity. It is characterized by the 



Chap. XXVI] FORMS OF MENTAL DISEASE 347 

development of irresistible morbid impulses which suddenly crop 
out and govern the actions in an entirely unpremeditated way, 
usually much against the patient's will. It may be the impulse 
to set fire to a building, to steal, to destroy property, to assault 
or to kill, to commit some unnatural sexual act, in persons who 
are not criminally inclined, and who, as a rule, abhor such con- 
duct. These morbid acts are likely to be followed by a feeling 
of relief. 

Defective Mental Development. — When in early life the brain 
cortex fails to develop normally, varying degrees of defective 
mentality are observed; the lighter ones are cases of imbecility; 
the graver ones, cases of idiocy. 

An idiot is a person devoid of understanding from birth. He 
perceives nothing intelligently. There are absolute idiots, fools, 
or middle-grade idiots, and a higher grade that are sometimes 
called simpletons. 

The imbecile is a feeble-minded person, his condition being 
due to arrest of development at an early age. There are low, 
middle, and high-grade imbeciles, according to the degree of 
intelligence and to the development of the moral nature; but 
all imbeciles, of whatever grade, are unstable, inefficient, and 
irresponsible. Imbeciles of high grade are often spoken of as 
"backward" or " simple-minded.' ' 

Idiocy, as well as imbecility, has defective heredity as the most 
frequent background for its development. Some idiots have 
abnormally large heads, while others have abnormally small ones. 
Faults of development, lack of symmetry, and other abnormal- 
ities are noted in the brain. Physical stigmata are numerous — 
receding foreheads, deformed ears, badly placed teeth, defective 
hearing, incoordination of the muscles, stunted growth, and many 
other defects make these children pitiable objects to behold. 
Some idiots are so defective that their attention cannot be fixed 
even momentarily, while others are capable of a little direction 
in the attention. Idiots are incapable of intelligent expression 
in speech or action. They cannot care for themselves or make 
known their wants. They are the prey of their ungovernable 
impulses and their animal-like propensities. 

The imbecile is able to care for his person and to attend to 



348 NURSING THE INSANE [Chap. XXVI 

his physical needs ; he often speaks intelligently, is not especially 
hampered in his muscular movements, and is capable of some 
facial expression. He shows a lessening of the normal mental 
and moral capacity. The power of attention is poor, and the 
ability to relate impressions and experiences to one another is 
slight, so that, although the person may see this and that clearly, 
he is usually unable to grasp the ideas resulting from his expe- 
riences, and so form conclusions. Such defective persons are 
very egotistical, overbearing, and selfish ; they are often cruel, 
too, because they are incapable of taking in the whole of any 
situation, and are only sensitive to what concerns themselves. 
As these defective children grow older, their incapacities become 
more and more apparent. Some imbeciles are sluggish and 
some are of the active type. The emotions are very unstable, 
and are often extravagantly expressed. 

Certain physical stigmata are seen in imbecility as well as 
in idiocy. Imbeciles as a rule are very susceptible to alcohol, 
and some of their most dangerous outbreaks are provoked by 
a slight indulgence in it. 

In spite of all the limitations of these defectives, institutions 
and teachers for these unfortunates have proven that some 
imbeciles can be trained to lives of self-controlled usefulness, 
even though in a narrow range, and that even the worst idiot, 
if taken early enough, can be trained to be less repulsive and 
less wretched than he would otherwise be if patient and intelli- 
gent efforts were not directed in his behalf. 



CHAPTER XXVII 

NUESING IN THE VARIOUS FORMS OF MENTAL DISEASE 

The probationer who undertakes the care of patients with 
mental disorders has much to unlearn as well as to learn. Even 
in this enlightened age the opinion still seems rather prevalent 
that mental invalids are to be humored in their fantastic 
beliefs, deceived and entrapped into conforming to necessary 
measures for their care and safety, and ordered about and 
coerced into obedience if inclined to rebel or resist. 

If, as probationers entering a hospital for the insane, you have 
believed that harshness and unkindness to patients are necessary 
means for subduing them, or are knowingly permitted, you will 
soon learn how erroneous is that belief. 

If you have thought that to be insane a patient must pre- 
sent the appearance usually ascribed to them — staring eyes, 
disheveled hair, disordered dress, and a raving manner — you 
have found yourself forced to abandon that view, and have 
gradually learned that the manifestations of insanity are about 
as many and as varied as are the classes and conditions of men. 
You have soon learned that some of the patients whose mentality 
is most grievously warped and distorted are capable of as quiet 
and restrained demeanor as the majority of persons outside a 
hospital, and that to be insane does not mean that all the men- 
tal faculties are conspicuously disturbed, altered, or impaired. 

Many of our patients, and some who are in reality hopelessly 
deranged, present nothing in appearance, dress, manner, or 
conversation that to an untrained observer would reveal their 
departure from mental health. Many others can maintain 
a proper behavior and rational conversation for given periods, 
and then are forced to give way to unmistakable manifestations 
of their disease. ' Certain cases appear to a casual observer only 

349 



350 NURSING THE INSANE [Chap. XXVII 

a little dull and dejected, others as merely stubborn, or boastful, 
or a little excited and loquacious, but " surely not insane," while 
still others are regarded as much-wronged "and perfectly sane" 
individuals who are unjustly detained in hospitals by the author- 
ities. Let me say, in connection with this erroneous notion, 
that our State hospitals are in such a crowded condition that 
we welcome every opportunity for discharging patients when it 
is wise or safe to do so. Some of the very patients who chafe 
most under hospital restraint, who appear to a casual observer 
to be unjustly detained, are persons we would be only too glad to 
be rid of did we not feel that dismissal would be followed by most 
unfortunate consequences, sometimes even by disastrous ones. 

If you have come here with the preconceived idea that patients 
are placed here merely for custodial care, in order to prevent them 
from doing harm to themselves or others, or from injuring prop- 
erty, and that their care is accomplished simply by keeping them 
behind bars and within closed doors, coercing them to conformity 
to the rules of the institution and prohibiting them from dan- 
gerous conduct, you will soon learn to alter that opinion. You 
will find that our State hospitals of to-day regard custodial 
care, though necessary, as the least important of their functions, 
and that the policy of the heads of these hospitals is to lessen 
restrictions, to remove restraints, and to permit just as much 
liberty as is possible with safety to each patient within their 
walls. You will find that entire wards, and in some cases entire 
buildings, are conducted on the open-door system, large numbers 
of patients going and coming at will during the day, and proving 
themselves entirely worthy of the trust reposed in them, at the 
same time that they are unquestionably insane, and in need 
of the care that the institutions afford. 

You will find that the aim of these hospitals is, in addition 
to permitting as much liberty as is compatible with safety, so to 
minister to the patients as to upbuild their sick bodies and 
restore their disordered minds ; and you will see that many a 
patient enters the wards in a reduced state of body and a dis- 
turbed state of mind, and, after receiving proper bodily care, 
and attention to the mental and moral needs as well, leaves 
the institution restored and in his right mind. 



Chap. XXVII] NURSING IN VARIOUS FORMS 351 

If you have held the opinion that the false beliefs of the insane 
are to be humored and indulged, you will soon learn that such 
is not the case ; on the other hand, you will also learn that it 
does little good to contend or to argue concerning delusions, 
and that a quiet diversion to some other topic is wiser than to 
attempt to convince a patient of his erroneous beliefs. 

If you have thought that the easiest way is the best way, and 
have considered it justifiable to resort to duplicity and deception 
in your dealings with these patients, you must abandon this 
false notion at the outset, as such methods are most repre- 
hensible, they defeat their own object, and are not to be toler- 
ated by any enlightened, high-minded person. 

The best results will usually be obtained by treating the 
patient as though he were a reasonable being, when this is at 
all practicable, and by letting him see at every turn that you 
want to help him in his difficulties, whatever they may be. 
They probably seem absurd to you. They are real to him. 
You also need to show him that in order to have order prevail 
and justice done to all, certain rules have to be obeyed, and that 
as members of one big family we are all here to help one another. 
By maintaining this attitude you call out the best in your 
patient and in yourself, and so provide a good groundwork of 
mutual understanding, which is necessary if you are to be a real 
help to your patient. 

It is not necessary for the nurse to know the name of the 
mental disorder from which the patient is suffering in order to 
nurse the patient properly. The important thing is to deal 
with the conditions. If there is excitement, seek to allay it; 
if fear, to remove it ; if anger, to dispel it ; and so on. 

In dealing with the insane we need to keep in mind that we 
are dealing with persons whose personalities have undergone 
a change, who are often unreasonable, and not amenable to 
ordinary methods of treatment. On the other hand, we need 
to remember that many of them can be appealed to in a perfectly 
reasonable way. While most of our patients are susceptible 
to real kindness, some are malicious and unapproachable, and 
will willfully misrepresent and misinterpret all that is done and 
said, and will sometimes go out of their way to be annoying to 



352 NURSING THE INSANE [Chap. XXVII 

the ones who are trying to help them. We will look more char- 
itably upon their ill-humored and malicious deeds, upon their 
abusive and disgusting talk, if we keep in mind that they are 
seeing as through a glass darkly, and that things are distorted, 
as well as seen in an unnatural light, and that it is for us to lead 
them to see more clearly if we can; but if that is impossible, 
we are here to bear with their warped personalities, and to 
prevent their false beliefs from working injury to themselves 
or others. 

We can best help our patients by teaching them self-control, 
and we can best teach self-control by making things as easy 
for them as possible, and not put their irritable nervous systems 
and unstable emotions to too strong a test. 

Kindly, patient suggestion, and respect for the patient's point 
of view, even when it is erroneous, and a persistent endeavor 
to help him to seek the best course in any situation that con- 
fronts him — these are true reformative measures. 

Even with so-called incorrigible patients, much can be done to 
win them to better ways of acting. Patterson Du Bois, in speak- 
ing of the relation of parents to children, gives us a hint as to 
how to deal with our "incorrigibles." He says that the true 
father says not, "I will conquer that child, whatever it costs 
him" but, " I will help that child to conquer himself, whatever it 
costs me." 

A nurse who lacks calmness and persuasive power cannot cope 
successfully with obstreperous patients. Neither can one who 
is not willing to take infinite pains; for it requires continual 
study, planning, and arranging of ways and means for drawing 
off the energy from mischievousness and vice to industry. Dr. 
Maudsley enjoins that we counteract commotions within the 
patient by an absence of commotion in his surroundings. 

Appreciation will do more to work a reform in your patients 
than criticism and condemnation. Reprimands emphasize 
faults, while commendation makes patients wish to do better 
in order to gain approval. One can often appeal to a patient's 
desire to please, or to his curiosity. Get him interested in things, 
keep his hands busy, show him how to do simple things well, 
stimulate him by approbation. First say, "Come, let me show 



Chap. XXVII] NURSING IN VARIOUS FORMS 353 

you how " ; later, "Now you do it"; still later, "See if you can 
show her how" (referring to another patient). Take an interest 
yourself, and your patients will. Appeal to their powers of 
imitation, emulation, ambition, pride, ownership, and above 
all to their constructiveness. Never appeal to their pugnacity. 
Make your patients love you, not by familiarity, nor by cod- 
dling, nor by favoritism, but by letting them see that you have a 
genuine and deep-seated interest in their welfare. 

Care of the Chronic Insane. — Perhaps it is well first to offer 
some suggestions as to the care of the chronic insane, since this 
class constitutes so large a proportion of our hospital population. 
It must be remembered that those we call the chronic insane 
are made up from the various disease-groups already described, 
and are by no means all to be handled alike. 

We may say in a general way that the care of the chronic 
insane consists in hygienic housing, and in training to good 
habits and to some useful work. Attention to ventilation, 
bathing, food, elimination, exercise, and sleep is included in 
hygienic care. Physical ailments need to be promptly recognized 
and relieved, if possible, and the patients' lives so regulated as 
to supply diversion as well as occupation. 

A great deal can be done to quell disorder and discontent by 
personal attention to the tastes and propensities of each patient. 
What works well with one will by no means always answer with 
another. The nurse who has the neatest, quietest, most orderly 
ward is the one who studies her patients and helps them to adapt 
themselves to one another and to their surroundings. Patients 
get into good ruts as well as bad ones. This is a very comfort- 
ing truth. It is owing to this truth that untidy and unclean 
patients can be trained to be cleanly, that bad postures and 
habits can be corrected, that good table manners can be developed, 
that idleness and apathy can be made to give place to industry 
and interest; that the habit of self -mutilation can be broken up, 
and that even long-standing cases of deterioration can, by pa- 
tience and persistence, combined with resourcefulness on the 
part of the nurse, be trained to orderly routine in some useful 
work. 

We need to remember in deteriorating cases, for example, in 
2a 



364 NURSING THE INSANE [Chap. XXVII 

dementia prcecox, to save all that there is to save of the mentality 
by keeping patients occupied and interested. It is surprising 
what interest can be aroused if one will but watch for whatever 
calls forth the slightest show of interest, and, taking that as a hint, 
fan the spark to a steady flame. It may be a love of dogs or 
cats, it may be liking to see things grow, it may be the doing 
of some work which the patient learned to do before his mind 
became so disordered — whatever it is, select the thing in which 
you find the patient will take an interest, and furnish him 
occupation along these lines. A pet dog belonging to an attend- 
ant, if given over to the care of a chronic patient, may furnish 
a real interest to that patient that will make her days anything 
but the colorless times they would be without it. She grows to 
consider the needs of the dog and to conquer her own ill-humored 
spells of sulking indoors. A family of kittens reared on the ward 
can furnish diversion for many, and really be the means of arous- 
ing apathetic ones. A window box of growing ferns, a single 
plant given the patient to care for, a sprouting sweet potato in 
a glass, a sponge rilled with canary seed, growing bulbs, branches 
of an apple tree or of a lilac bush forced to bloom in the house 
in early spring, a canary bird to care for, even a pet mouse — 
these simple means are often a great help in awakening the 
attention of patients in things outside of self, and later of lead- 
ing them to doing things. 

In all forms of insanity where the judgment is much impaired 
the nurse needs to watch over the patients and protect them 
as one would a child. Many such patients are too demented to 
complain when they suffer from physical ailments. You will 
need to watch such patients to see if they eat poorly, if they 
cough, and perhaps expectorate slyly in out-of-the-way places, 
to see if they have a fever, or need attention to the bowels. 

In trying to teach inattentive patients to attend to things in 
order to learn to do even the simplest tasks, you need to know 
that there are easy stages by which this may be brought about. 
First, arrest the patient's attention. This may be done in various 
ways, by variety, or novelty, or by some sudden or unusual way 
of calling his attention to it ; then by repeatedly arousing his 
interest in it you will find that he gradually learns to have a 



Chap. XXVII] NURSING IN VARIOUS FORMS 355 

livelier appreciation of it. Then is the time to get him to act 
concerning it; to take hold and do it himself; and from this 
stage he gains a real personal interest in the thing, so that he 
has a love for it, or a desire to excel in it, as the case may be ; 
and when this point is reached, the thing comes to be part of 
his experience and to have a real relation to the rest of his life. 

Patients who are inclined to be careless and slovenly in dress 
can never be won over to neatness by indifference on the part of 
the nurse. There is too much of a tendency to think that any- 
thing is good enough for such persons, and misfit clothing, 
mismated hose, boots laced up with a corset string, or "any old 
thing" is put on the patient. Try what you can do to stimulate 
pride by an entirely different course ; take special pains to put 
on a bright-colored gown or a new pair of shoes, to arrange the 
hair becomingly, and see what this course will do. 

Patients who are destructive of clothing must be furnished 
with material not easily destroyed, but in addition to that should 
be furnished with a legitimate outlet for pent-up energies, if the 
habit of destructiveness is to be broken up. 

When patients are restless, learn whether it is from lack of 
occupation and boredom, from physical discomfort, or mental 
unrest, or anxiety. When the cause is ascertained, seek to 
remove or to alleviate it as far as possible. 

When patients are violent, it is either from anger, from maniacal 
excitement, from epilepsy, from impulsive outbreaks, from pain 
and discomfort, or as a result of false perceptions or beliefs. 
Here, too, the cause of the violence should be sought and alle- 
viated. In many persons subject to violent outbreaks you 
will observe that certain symptoms are pretty likely to precede 
the violence. This will put you on guard. In certain ones the 
outbreak is preceded by stereotyped complaints, in others by 
extreme pallor, or a peculiar tremor of voice, or by profanity. 
Impulsive cases usually give no warning. Such patients should 
be carefully watched that they do not have access to things 
they could use as weapons. 

When it is necessary to approach a patient known to be 
violent or homicidal, always have plenty of help at hand, if 
possible. Let one attendant grasp one arm, one the other, at 



356 NURSING THE INSANE [Chap. XXVII 

the wrist and elbow, holding them out straight, and using no 
more force than necessary. A third attendant may stand be- 
hind and hold the chin if necessary, to prevent biting and spit- 
ting. Walk the patient backward and seat him in a chair. Do 
not hold him after violence subsides. Let him scold if he is so in- 
clined; it is better that the excitement finds an outlet in noise 
than in violence. Hot packs, if prescribed by the physician, also 
isolation, are soothing measures in these cases, if properly applied. 

There may be rare occasions where it will be necessary to 
approach a violent patient with a blanket, throwing it quickly 
over the head long enough to enable you to get control of him, 
perhaps to get a weapon away from him. But such cases should 
be reported to the office at once. Seclusion is often profitable 
in these cases, but permission should always be first obtained, 
except in grave emergencies. 

Sometimes when a violent patient, perhaps with a weapon, is 
in a room, and it is necessary to enter the room before his rage 
subsides, the foremost attendant may approach by carrying a 
mattress lengthwise in front of him, as a shield, and the others 
rally their forces as opportunity offers. Violent men patients 
about to strike may be prohibited if one can seize the coat from 
behind and quickly pull it down upon the arms ; spitting and 
biting patients may, if necessary, be checked by holding a towel 
in front of the face, but never over the mouth. In struggling 
with violent patients, whatever the provocation, never apply 
pressure to the throat, chest, or abdomen. 

The tactful nurse, whose supervision and management are 
what they should be, will seldom let things reach a physical 
contest. A physical struggle with a patient is degrading to 
both nurse and patient. It lessens the patient's self-respect 
and leaves him with a feeling of degradation, and the memory 
of the struggle engenders bitterness between nurse and patient 
that is difficult to overcome. 

Certain patients will at 'times be untidy and boisterous in spite 
of all one can do to counteract these tendencies. Such should be 
kept in rooms in the rear of the building; when taken out on 
the grounds, they should be kept in the least frequented parts. 

There are times when to go on certain wards is to say with 



Chap. XXVII] NURSING IN VARIOUS FORMS 357 

Uncle Toby in "Tristram Shandy," "Our armies swore terribly 
in Flanders, but nothing to this ; " but deplorable as are some of 
these manifestations, there is no question but that the noise 
and violence, and much of the profanity and obscenity, can be 
greatly lessened by furnishing these same patients with occu- 
pation and exercise, and by reducing causes of irritation to 
a minimum by constant judicious oversight. 

In all cases of exhaustion, from whatever cause, the main things 
are to build up the body, promote sleep, conserve the strength, 
and see that the bowels, kidneys, and skin are doing their work. 

Light liquid diet at regular intervals should be given as ordered. 
Exhausted cases should especially be fed in the early morning 
hours, when the vital powers are at their lowest ebb. Saline 
hypodermatic injections, and saline enemata, may be called for. 
Light and noise should be reduced to a minimum. The patient 
should be kept in bed, warm baths and other hydriatric meas- 
ures may be employed to reduce restlessness and delirium. The 
patient should not be argued with if exhausted, and if delirious 
should not be left alone an instant day or night. Exhausted 
and delirious cases should not be considered well until they have 
regained their former weight. 

The nursing of delirious and stuporous cases is practically the 
same, and applies also to exhaustion and infection cases, to 
stupor from dementia, from shock, hemorrhage, head injuries, 
typhoid, and the like. 

Cases of stupor, whatever the origin, need bodily rest, extra 
nourishment, extra attention to the functions of defecation 
and urination; they need frequent administration of water, 
frequent baths, and building-up treatment generally. They 
should not be expected to lift their fingers, even; every atom of 
strength should be conserved; everything should be done for 
them kindly, quietly, and with apparent leisure. All noise, 
bustle, and confusion must be avoided, for though apparently 
unconscious, the injurious effects on the nerves of these dis- 
turbing agencies are just as pronounced as though the patient 
perceived them. 

If the temperature is subnormal, as is often the case, attention 
to sufficient clothing and coverings and to artificial heat is needed. 



358 NURSING THE INSANE [Chap. XXVII 

The sensibility being reduced, great care is required to prevent 
burning from applied heat. The weak heart's action, seen in 
the slow, small pulse, and cold, blue extremities, shows how 
important it is to conserve and add to the strength at every 
turn. 

If the skin is dry, inunctions are indicated. The tendency 
to bed sores has to be constantly guarded against. The in- 
voluntary evacuations of urine and feces require the utmost 
attention and cleanliness, and the tendency to retention of urine 
and over-distension of the bladder is equally important. The 
drooling of saliva, the accumulations of secretions in the corners 
of the eyes and in the nostrils, call for fastidious care on the 
part of the nurse. The rapidly forming sordes on teeth and 
tongue demand assiduous care. 

Patients that are delirious or in a stupor require pains- 
taking administration of food, as well as in regular and suffi- 
cient quantities. Sometimes, when urging them to swallow 
food is of no avail, rubbing the lips with the spoon will cause 
them to open the mouth and swallow, even though they are un- 
conscious. This will also often work in the giving of medicine. 

The utmost care is needed if artificial feeding is resorted to, 
and this should never be undertaken except in the presence of 
the physician. 

The treatment of the Intoxication psychoses varies according 
to the various forms. The withdrawal of alcohol is one of the 
first things to do. Treatment is then directed toward pro- 
moting sleep, and nourishing the patient, watching the excre- 
tory functions, and in preventing injury to self and others. 
The moral treatment consists in encouraging the patient in 
the belief that he can conquer the habit when he is properly 
fortified by the treatment; and also in making him see clearly 
how odious it is that he has been a slave to the habit for so 
long, and how desirable it is that he abandon it now for all 
time. 

In the delirious forms, remember that it is very injurious to 
use mechanical restraint. Seek to allay delirium by warm baths 
and to keep the patient in bed by putting him back as often 
as he attempts to rise, but do not restrain him in a safety sheet 



Chap. XXVII] NURSING IN VARIOUS FORMS 359 

or a pack. Patients with delirium tremens are likely to attempt 
to leap out of the window. 

The treatment of Morphinism and of Cocainism are very similar. 
Complete abstinence can usually only be secured by placing 
the patient in an institution. The relatives must refrain from 
dictation, leaving the control of the case to the physician. The 
patient should be put to bed. Rapid or gradual withdrawal 
of the drug is decided upon by the physician. Watch for ab- 
stinence symptoms and for signs of collapse. Heart stimulants 
may be called for in some cases. Abdominal packs, salt baths, 
and other baths, intestinal douches, the copious drinking of 
water, and massage are of great help to promote sleep. If 
both morphine and cocaine have been used in a given case, 
cocaine should be withdrawn first. The diet should be light. 
Small quantities of food should be given at frequent, regular 
intervals. Tea and coffee are helpful in allaying restlessness. 

It is well to put the patient in a darkened room and let him 
sleep in the middle of the day at the beginning. Later he will 
begin to feel sleepy at night, and more and more sleep will be 
secured. 

Pains must be taken at every turn to establish confidence 
in the curative measure used by the physician, and to maintain 
this confidence. Morphine habitues are vacillating and are all 
the time wanting a change of treatment. The patient, even if 
a physician, must be made to understand from the start that he 
must give himself over entirely to the direction of the physician, 
if he is to be cured. 

The treatment as a rule should extend over six to ten months, 
in order to cover the periods of restlessness and irritability that 
are likely to recur every few weeks, at which times, if unguarded, 
patients are especially liable to relapses. It is difficult to per- 
suade a patient to submit to the treatment after the sense 
of well-being and the marked improvement appear (usually 
between the second and third months of treatment), but unless 
he can be so persuaded the early treatment is of little avail. 

Surveillance must be maintained long after active treatment 
has ceased, and the after-care must consist in removing all ner- 
vous strains and all temptations as far as it is possible to remove 



360 NURSING THE INSANE [Chap. XXVII 

them. A radical change in one's life is desirable on leaving 
the institution. Brain workers should become muscle workers 
and lead wholesome out-of-door lives. 

In the treatment of Dementia Prcecox, rest in bed and nursing 
directed to improving the nutrition are important in the begin- 
ning. Forced feeding may be necessary; cold baths, friction, 
and spinal douches help to improve the sluggish circulation and 
the shallow, irregular breathing; abdominal packs are also of 
use. Especially important is it to train to habits of cleanliness. 
The resistance so common in these cases can sometimes be cir- 
cumvented by asking the patient to do just the opposite to 
what you wish him to do, 

As these patients improve physically and are able to be about, 
efforts should be directed toward educating the undisciplined 
nature as far as possible, by teaching self-cqntrol and by requiring 
the patients to do instead of dream. Each day they should be 
patiently trained to accomplish certain tasks, care being taken 
not to select things too hard for them. 

Deteriorated cases should be especially protected in cold 
weather, as they are too dull to tell when they are insufficiently 
clad. They should also be guarded against burns and scalds, 
not allowed to lean against hot pipes, or to turn hot water on 
themselves. Distention of the bladder must be guarded against. 

The treatment in cases of General Paresis of the Insane is to 
safeguard the patient and his friends from his numerous im- 
practicable schemes, or from his violent outbreaks, and to 
regulate his diet, sleep, and exercise in accordance with his 
needs and strength. Uncleanliness must be forestalled by 
watchfulness, also accidents arising from the patient's stupidity, 
clumsiness, and uncertainty of movement; prevention of bed 
sores is needful, and it is especially important that paretics 
be closely watched when eating, to prevent choking. In all 
cases of paresis, it is better to feed the patient than to let him 
feed himself. One must watch that the paretic does not retain 
urine and feces. Saline infusions and saline enemata are very 
useful in paresis. 

In the treatment of Melancholia one of the first things is to 
remove the patient from familiar surroundings and from his 



Chap. XXVII] NURSING IN VARIOUS FORMS 361 

friends, as these only serve to aggravate his condition. It is 
a great mistake to attempt to divert the patient, to take him on 
a journey, or to insist upon his seeing company. These well- 
meant efforts to cheer him up are not only useless but even 
harmful. The patient should be put in bed and kept there the 
greater part of the time, and required to take small quantities of 
easily digested food at frequent intervals. Patients will often 
refuse food from a feeling of unworthiness or from fearing that 
they are robbing some one else. It is not well, especially in the 
former cases, to appear to notice the patient's objections, nor to 
urge him to eat, but leave food near, and give him a chance to 
eat unnoticed. The free action of the bowels is especially im- 
portant. Warm baths are a decided help in favoring sleep and 
in mitigating the restlessness that overtakes the patient from 
time to time. Sometimes compresses over the heart are helpful 
in allaying the agitation so common in this disorder. 

Visits from friends should be absolutely prohibited until a 
decided improvement is observed. 

These patients should be under continual observation day and 
night. As they get stronger they should be drawn out in con- 
versation to prevent brooding, and later should be furnished 
with light, interesting occupation. The danger of suicide must 
never be lost sight of, even after marked improvement is noted. 
Especially should patients be safeguarded in this particular at 
night and early mornings, when their despondency is often most 
profound. It is a good plan to give suicidal patients a cup of 
hot milk on their awaking, as this serves to lessen the morning 
depression. 

It is surprising what schemes suicidal patients will evolve to 
obtain means for self-destruction. They will crawl through tran- 
soms and wickets, make keys and unlock doors, try to drown 
themselves in the bath tub, to hang themselves with a sheet, or 
with their nightgown made into a rope, or with the cord from a 
bath robe, or a necktie or apron string; they will eat soap, drink 
ink, paint, or disinfectants, and break windows or tumblers to se- 
cure sharp pieces of glass with which to cut their throats or wrists. 
They are often very shrewd, and select times when something 
unusual is going on and the nurses are somewhat off their guard; 



362 NURSING THE INSANE [Chap. XXVII 

for example, the nights of the dances, when visitors are on the 
wards, or when other patients are demanding extra attention. 
Suicidal patients should never be allowed to lie with their heads 
covered, as they may strangle themselves in bed with the nurse 
sitting close by. They should be undressed each night, and 
clothing and bed carefully searched to make sure that they 
have secreted no weapons during the day. 

When out walking near bodies of water, going downstairs, 
or when near clothes chutes, suicidal patients must be carefully 
guarded lest they make a sudden spring and drown themselves, 
or dash themselves down from a height, or throw themselves in 
front of horses, or trolley cars, or automobiles, or lest they pick 
up glass or tin with which to cut an artery. Some suicidal per- 
sons will save their medicines slyly with a view to accumulating 
enough to form a fatal dose ; some will feign cheerfulness and talk 
hopefully of what they intend to do when they get home, just to 
get the nurse off guard so that they can accomplish their own 
destruction. 

Much can be done with depressed cases in assuring and re- 
assuring them, day in and day out, that they will get well, that 
their suffering, hard as it is, will have an end — the turn in the 
lane will come at last. Lead them out of themselves by mild 
diversions without appearing to take too much notice when they 
begin to respond to your efforts. 

Patients suffering from Senile insanity cannot be taught very 
much, because memory is so impaired; neither can they be rea- 
soned with very successfully. Our efforts at helping them must 
consist of repetition and patience when necessary to train them to 
certain things, and in time we may get an automatic obedience. 
We must deal with them much as we would with a very young 
child, reward them when they do the right things, express regret 
and disapproval when they do the wrong ones, but do not let 
expressions of disapproval take the form of unkindness or harsh- 
ness. These patients need to be carefully watched to prevent 
self -in jury, not from intention so much as from loss of judg- 
ment and insight. They think themselves capable of doing just 
as they used to do, and in this way often come to grief. If very 
feeble, they should be kept in bed. They need to be safeguarded 



Chap. XXVII] NURSING IN VAEIOUS FORMS 363 

against falls on polished floors and on wet and icy places. Their 
bones are very fragile, and slight falls result in fractures and dis- 
locations ; sometimes the force exerted in dealing with them, 
when they are resisting, results in fractures. 

Senile patients are very trying because they are so fussy and 
meddlesome and so incapable of being made to understand things. 
Because of this they must be protected from irascible and violent 
patients who will attack them when angered by their meddle- 
some ways. Senile cases worry over trifles ; they suffer if they 
drop a pin and can't find it ; they are in a hurry about every- 
thing, in a hurry to get to places, and in a hurry to get back. 
They live in the present moment, but weave the events of the past 
in their talk as though these were taking place also. They often 
suffer from persecutory beliefs, and need to be soothed as one 
would a tired, fretful child. 

The nursing of Manic-depressive insanity should consist 
largely in keeping the patient well nourished, and in securing the 
greatest possible mental quietude. 

Although the excited and depressed types are so varied in their 
manifestations, certain measures apply to the one form equally 
as well as to the other. Careful observations of the weight, at 
least twice a month, should be made and recorded. So long as 
the weight falls in either form, a favorable prognosis cannot be 
given, even though the mental state should show improvement. 
Attention to easily digested food given at regular and frequent 
intervals is all-important in both forms of the disease. Rest in 
bed is likewise equally important in both; for the excited cases 
because they expend so much strength in extreme psycho- 
motor activity, and for the depressed forms because nutrition 
and strength are at the outset usually below par. 

Isolation also is desirable in the treatment of these opposite 
conditions. Excited patients, with their exaggerated impres- 
sionability, their ready reactions to all sense impressions, need 
to have all external stimuli reduced to a minimum, since every- 
thing that the patient sees, hears, and experiences serves as an 
added excitant. The need, then, is to lessen brain activity as 
much as possible. If such patients cannot be cared for in a 
room by themselves, a certain amount of isolation can be secured 



364 NURSING THE INSANE [Chap. XXVII 

by screening the bed and by keeping the infirmary as quiet as 
possible. They should not be urged to exert themselves nor to 
take an interest in things in the acute stages, but time, rest, 
and feeding should be given a chance to do their work. 

Constant supervision of excited patients is needed to prevent 
them from carrying out mischievous, belligerent, or destructive 
impulses. Infinite tact is required in dealing with them. We 
have seen how their self-valuation is heightened. This shows 
itself in their boastfulness, their monopolizing of the attention, 
and their absurd attempts at personal adornment. Where self- 
feeling is so strong it is likely to be equally sensitive to slights or 
criticism. Where self-love is hurt by inattention or reproof, or 
humorous or sarcastic remarks concerning their appearance or 
conduct, they are much given to abusive and violent outbursts. 

Avoid laughing at your patient's witty sallies or encouraging 
his fantastic dress or grotesque behavior. These may be very 
amusing, and it may be a temptation to draw the patient out ; but 
remember that psychic rest is what he needs, that soothing in- 
stead of stimulating influences should be provided. At the same 
time these manifestations should be met with the nicest tact. 
It is best to humor manic patients within reason, to avoid seem- 
ing to oppose, to restrain, or to contradict them, nevertheless 
you are to maintain a watchful eye over them. By timely sug- 
gestions and diversions and tactful means you can, all unknown 
to them, safeguard them from their impulses and prejudicial 
tendencies. 

Study each patient, learn what things excite him, and how he 
is likely to react to them, and forestall these reactions by re- 
moving the causes, or by removing him from the causes, in such 
a way that he does not suspect that he is being managed. This 
can be done without resorting to insincerity or untruth. Make 
him no false promises. Let him feel that he can always rely 
upon what you tell him. 

Erotic patients must be prevented from making shocking 
exhibitions of themselves. Their tendency in this particular 
needs to be constantly borne in mind, and when men are on 
women's wards, or women on men's wards, these patients can be 
quietly engaged in some remote part of the hall, screened, or at 



Chap. XXVII] NURSING IN VARIOUS FORMS 365 

least provided with a nurse close at hand to prevent as far as 
possible unseemly conduct and often indecent and homicidal 
attacks. For sexual excitement often takes the form of extreme 
violence toward the opposite sex, and sometimes attacks begun 
in a playful mood may suddenly change to dangerous assault. 
Knowing that your patients are liable to these manifestations 
should keep you on guard to prevent them. The ounce of pre- 
vention here is earnestly recommended. 

Try especially to prevent patients from starting the habit of 
masturbation. Keeping the genitals scrupulously clean by daily, 
and if necessary hourly, attention, and keeping the rectum empty, 
combined with cold sitz baths, and with efforts to divert the 
patient when eroticism makes itself apparent, are aids to this 
end. Later, bodily labor sufficient to tire the patient is an aid 
in conquering the habit. 

Excessive spitting, smearing the body and walls with feces 
and with menstrual blood, tearing clothing and breaking fur- 
niture, are all manifestations of run-away impulses, and these 
can all be reduced to a surprising degree if hydriatric measures 
are faithfully and intelligently applied. Attention to the bowels, 
not permitting the rectum to remain loaded, and not allowing 
the patient to have access to the voided evacuations, will also do 
much to obviate uncleanly habits. Some patients even need to 
be watched to prevent them from drinking urine and eating 
feces. 

Because of hyperesthesia of the sense organs, excited cases 
especially should be kept in moderately lighted or even darkened 
rooms, and all noises lessened as far as possible. Intercourse, 
in acute stages, should be limited to that of the nurse and 
the physician, if an ideal treatment can be carried out, and the 
isolation gradually relaxed as improvement progresses. 

In excited cases, if the bodily strength and nutrition show 
but little reduction, exercise under advice of the physician 
may be encouraged, and will usually furnish a suitable outlet 
for the superfluous energy of the patient; but in acute stages, 
as a rule, bed treatment is the most rational and successful. 
One has to remember that there is a tremendous output of energy 
in these excited cases, and that this must be compensated for by 



366 NURSING THE INSANE [Chap. XXVII 

generous feeding, without taxing the alimentary system beyond 
its strength. Milk diet, with the addition of limewater, eggnogs, 
broths, jellies, vegetables, and fruits are called for. Animal 
food and stimulants should be avoided as tending to increase 
excitability. Highly seasoned food, strong tea and coffee, 
and tobacco are counter indicated here. These patients need 
plenty of water; as a rule, five or six glasses a day should be 
regularly administered in both the maniacal and depressive 
forms. 

At the outset with excited patients warm baths should be 
administered; at first, a full warm bath of 90° to 95° F. for 
fifteen minutes, later in the day for thirty minutes, still later for 
an hour, till, the patient becoming accustomed to them, baths 
of two to four hours, or even all day, may be administered. 

Hydriatric measures are the most successful means we have to 
allay both the extreme restlessness and the insomnia which are 
often grave features of maniacal cases. If the heart is weak and 
the prolonged baths are not well tolerated, warm packs every 
four or six hours are a good substitute. 

As restlessness decreases and baths are discontinued, wheel- 
ing the beds into well-aired sun rooms or on verandas, or having 
the patient sit in an invalid chair on the grounds, are valuable 
adjuncts to the treatment. Nourishment, an abundance of fresh 
air, baths, and a sympathetic and judicious attention to the 
psychic state are the things to be aimed at in the treatment of 
manic-depressive patients. 

It must be remembered that manic patients are generally insen- 
sible to cold, to pain, and to fatigue; yet the effects of these 
agents are just the same on the bodily economy as though the 
patient sensed them, so that the need for increased nutrition and 
soothing measures is very great. Because of their insensibility 
to pain, they need to be watched for other indications of physical 
disorders that in sane persons ordinarily make their approach 
known by the forerunner pain. 

Depressed patients need isolation because of their tendency to 
put the most unfavorable construction upon every happening. 
It is bad for them, too, to contrast and compare their condition 
with that of others. They are painfully affected by the dis- 



Chap. XXVII] NURSING IN VARIOUS FORMS 367 

orders of those about them, are prone to reproach themselves 
with having brought them about, and tend to refer every pos- 
sible occurrence to themselves in a most exaggerated way. 
They should be required to rest in bed and should not be annoyed 
by well-meant but injudicious advice to exert themselves in 
overcoming their inactivity, and to " cheer up." As the physical 
strength improves, a judicious application of stimuli may be made, 
but it is cruel to tell a weak, dejected patient to " get out of him- 
self/' and " cheer up," when he is having all he can do to exist, 
and to do as well as he does. Platitudes only embitter him, and 
diversions are likely to irritate rather than help. This is the 
grave mistake that is made by friends and physicians at the out- 
set of these troubles. The patient is advised to travel, to seek 
diversion, to exert himself to keep up with the family and social 
demands when nature is already crying Halt ! 

One of the most beneficial results to be gained by putting a 
depressed patient in a sanitarium or a hospital is the separation 
from family and friends, however great the attachment between 
them may be. In fact, the greater it is, the greater is the need 
of removal. Friends cannot forbear from arguing, from urging to 
action, from trying to amuse, from encouraging, to a degree that 
only accentuates the already self -centered state. Or, if they do 
not take this course, they reproach or ridicule, or threaten, or at- 
tempt unwise discipline, or force, or use other injudicious tactics. 
Because of this, and because letters and visits from friends only 
serve to keep alive the painful sense of the conditions under 
which the disease developed, correspondence with and visits from 
friends should be discouraged during the acute depressive stages. 

It is a difficult lesson to learn that arguments directed toward 
delusions are practically useless in most cases. When em- 
ployed, they should be used by the physician whose business it is 
to study his patient and learn when the propitious moment has 
arrived for the use of this measure. It is well for the nurse to 
remain passive before delusions, ignoring them, changing the 
subject, and avoiding things that will call up morbid ideas. 

In depressed cases, animal food is to be added to the diet al- 
ready outlined for maniacal cases, and mild stimulants may also 
be called for if patients are anemic. 



NURSING THE INSANE [Chap. XXVII 

Refusal of food may be the result of retardation merely, from 
inability of the patient to rouse himself enough to lift the spoon to 
the mouth. This should, of course, be met by regular feeding, 
due care being given to small mouthfuls, and to leisurely feeding. 
Save these inactive patients all unnecessary exertion. Let them 
feel that it is a pleasure to do for them until such time as they 
acquire strength and energy to do for themselves. Let them 
know that you recognize that their inactivity is not laziness but 
illness. 

Some refuse food because they believe that their stomachs 
are gone, or that some part of the alimentary canal is hopelessly 
obstructed. Arguments will do little good here. If leaving 
food about where the patient can get it unobserved does not 
suffice (a device that works in many cases), and the nutrition is 
suffering markedly, artificial feeding by means of the nasal tube 
may need to be resorted to. 

Anemic, depressed patients who are troubled with insomnia 
are often greatly benefited by a full meal at bedtime. 

Warm baths and packs, as a rule, are beneficial in the depressed 
forms, but in many of these cases cold baths and packs also work 
well, especially in the mildly depressed. 

Systematic attention should be given to the evacuation of 
bowels and bladder. The intestinal action is usually sluggish, 
and fecal impaction and a distended bladder, especially in the 
stuporous forms, are to be guarded against. 

Massage and passive movements are needed to counteract 
physical inactivity. Anemic patients need a superabundance 
of fresh air and sunlight at the same time that they need extra 
clothing and warmth. Select the least-exposed beds for such 
cases, give them sufficient covering, especially at night, and hot- 
water bags when necessary; be careful, though, not to weigh 
them down with clothing, particularly on the chest. Sunlight is 
markedly beneficial in cases of depression. The common helps 
at command for the restoration of patients are so likely to be 
overlooked that at the risk of repetition I wish to remind you of 
these well-known but too sparingly used remedial measures. 

Suicidal attempts are not common in manic-depressive insanity, 
but it is not safe to go on this supposition. Every case of de- 



Chap. XXVII] NURSING IN VARIOUS FORMS 369 

pression, whether it be one of the disease-process we are consid- 
ering, or that of the melancholia of involution, or a depression 
accompanying any other mental disease, needs to be under con- 
tinual surveillance in this respect. There is no knowing when 
the impulse to end mental suffering may overtake a patient ; and 
the sight of means to do ill deeds makes ill deeds done perhaps 
before nurses or physicians have suspected that the patient was 
suicidal. 

If the foregoing treatment is intelligently applied, especially 
the hydriatric measures, there will be little need of employing 
mechanical restraint, even in the most excited cases, but patients 
with extreme suicidal or homicidal tendencies and some cases of 
uncontrollable destructiveness seem to justify it occasionally. 
Drug restraint is rapidly being dispensed with in all modern 
hospitals. 

The application of a safety or protection sheet, or a camisole, 
or of any sheet or bands to restrain a patient in bed or chair, 
constitutes restraint. It sometimes becomes advisable in the 
opinion of the physician to employ these means to prevent a 
patient from injuring himself or others, or to retain surgical 
dressings, or to guard against exhaustion or exposure. The 
employment of any form of restraint, or of seclusion, is only per- 
mitted on a signed order of a physician, setting forth the reasons 
for its application. The restraint order must be turned in daily 
to the office, with the nurse's signature and statement as to when 
the restraint was applied and when removed. 

If a nurse or a physician will take pains to put himself in a 
restraining sheet even for an hour, the order or the desire to resort 
to it for the control of troublesome patients will be long in forth- 
coming, if the Golden Rule is a part of his practice. It is incred- 
ible the amount of discomfort that can be experienced in one of 
these so-called humane contrivances, even under the most favor- 
able conditions. The writer knows whereof she speaks, having 
once voluntarily caused herself to be placed in one on one of the 
quiet infirmary wards. The charge nurse was instructed to 
apply the sheet and to keep it applied for three hours regardless 
whether or not the physician changed her mind after being in the 
sheet for a time — a necessary precaution if anything like a test 
2b 



370 NURSING THE INSANE [Chap. XXVII 

of the thing was to be made. It is not pleasant even at this 
distant date to recall the experience, yet this was undertaken 
under the most favorable conditions, with nurses ready to keep 
the ward in its most agreeable condition, ready to attend to the 
slightest want that might arise, with the patients interested in 
the experiment, and, by their different ways of acting and com- 
menting about the situation, furnishing means of interest that 
made the time hang less heavily than it otherwise would. Further 
than this, the knowledge that the restraint was voluntarily as- 
sumed, and that the situation was not without some novelty, 
contributed an element of interest. Then the experimenter 
was not a sensitive, overwrought, restless patient, and had none 
of the many other discomforts to contend with that patients in 
restraint ordinarily have; yet the amount of discomfort ex- 
perienced on that moderately warm day in early summer was 
enough to make the physician an enemy to the safety sheet, 
except in extreme cases. No one realizes, for instance, how many 
times a day he brushes away a fly or a stray hair straggling across 
his forehead, or scratches his nose, or needs to use his hands for 
countless acts that are attended to automatically, unless he is 
prohibited in some way. With a tear trickling down the cheek, 
or the nose in need of attention, or perspiration running down 
the body, to mention only a few of the things to contend with, 
one can see how the discomforts of an excited, irrational patient 
may be increased tenfold. 

A new, acute patient should never be placed in restraint till 
all other means have been faithfully tried, and then only in the 
presence of the physician. 

When restraint is actually deemed necessary, certain things 
must be carefully looked after. The patient must receive atten- 
tion as to the evacuation of bowels and bladder before its applica- 
tion, and must be taken up or given the bed pan at least once an 
hour to afford opportunity to urinate. Nervous persons need to 
void urine very often, and the recumbent posture seems to favor 
the secretion of urine; in excited cases great discomfort may be 
felt in this respect without the patient being aware of what causes 
it. If sufficient opportunity is not given, certain patients will 
urinate in the bed, and soon acquire unclean habits. 



Chap. XXVII] NURSING IN VARIOUS FORMS 371 

Whatever restraint is used, it must be examined carefully to 
see that no chafing or constriction is possible. Wrinkles in the 
underwear and in the bedding should be smoothed out, and, in 
restless patients, frequently smoothed out; perspiration should 
be frequently removed from the body, the face bathed often and 
dried carefully, drink offered again and again; pains should be 
taken to keep stray hairs and tossing locks from falling over the 
face, and flies from lighting on it; in feeding the patient, care 
should be taken not to spill liquids on the patient's face or neck, 
and to prevent crumbs and other food from falling down the 
neck and getting on the chest and under the shoulders. Strug- 
gling patients must be closely watched to see that they do not 
twist about and get in such positions that they constrict their 
necks or injure themselves in any way. A tendency to rub the 
chin and face and so cause severe chafing from contact with the 
strong canvas of which the sheet is made must be guarded 
against. The danger of bed sores needs to be borne in mind, too, 
because of the somewhat restricted position of the patient. 
Ankle straps should not be used. 

In the treatment of paranoia, aside from providing hygienic 
care, the chief helps are in furnishing suitable diversion and in 
removing irritating influences as much as possible. Dr. Fred- 
erick Peterson has pointed out that labor often acts as a counter- 
irritant, and that in action the pent-up nerve force is drawn away 
from morbid thoughts and feelings, just as in idleness these are 
intensified and undergo further perversions. 

It is well to let these patients talk out their troubles. The 
interest shown by the listener is soothing to the patient, and once 
a common ground of sympathy is found, you can the more easily 
lead the patient away from the topics that engross him to others 
that will divert him and enlarge his field of interest. 

A deluded person hangs painted chains on painted hooks. 
What we need to do is to put up real hooks for him, and in time 
he may come to hang real chains upon them. 

It will often do a patient good to talk matters over frankly 
with him, and point out his faulty reasoning, but this course 
should be left to the physician. And because you hear the phy- 
sician argue with a patient about his delusions, do not follow 



372 NURSING THE INSANE [Chap. XXVII 

this up with your own arguments, unless the physician explicitly 
instructs you to do so. An officious nurse, rehearsing the things 
she has heard the physician say, may undo all the good that oc- 
casional suggestions and arguments may do. As a rule, confine 
your talk to matters of fact, to happenings, to things of interest, 
and the like, and leave to the physician the arguing. 

Some paranoiacs can be helped to a clearer, saner way of 
looking at things if in some indirect way a hint or a suggestion is 
dropped. For example, if some such thought as the following 
could, as it were, accidentally fall in their way: " This is a busy 
world, and no one really has time to sit right down and hate you. 
The only enemies we have are those we conjure forth from our 
own inner consciousness. One thing, we are not of enough 
account; and the idea that a man has enemies is only egotism 
gone to seed." 

While we are not to combat, directly, insane delusions, we are 
not, on the other hand, to encourage them. If patients believe 
that they are kings and queens, or hold other absurd beliefs, it 
only fixes these the firmer to address them so. A patient in 
mind has been helped to an attitude of insufferable vanity and 
conceit largely by the injudicious flattery of nurses, visitors, and 
even physicians who thoughtlessly humored him by adding to 
the flattery till his colossal vanity now knows no bounds. 

Patients who have delusions about being poisoned are often 
helped to take sufficient nourishment by the nurse appearing 
rather indifferent as to whether they take food or not, at the 
same time that they are given a chance to see their trays pre- 
pared from the general supply that does no harm to others. 
Sometimes the nurse may pour herself a glass of milk and drink 
it in the patient's presence, immediately pouring milk from the 
same source in the patient's glass and quietly setting it before 
her, letting her draw the inference. Or sometimes it works 
well to let suspicious patients help themselves from the general 
supply of food as it comes up in the dumb-waiters, before it could 
possibly be tampered with by any one on the ward. 

In the treatment of epileptic insanity one of the first things is 
to regulate the diet. There is need to keep the patient well 
nourished to counteract the effects of the nervous storms he 



Chap. XXVII] NURSING IN VARIOUS FORMS 373 

undergoes from time to time. Food should be taken regularly 
and in moderation, and the bolting of food is especially to be 
guarded against. Meat finely cut up may be allowed at the 
noon meals. Light suppers only should be eaten. Fried foods, 
pork, veal, cabbage, and other food difficult of digestion should 
be prohibited; also alcohol. Many physicians prohibit the use of 
salt except in very small quantities. The excretory functions 
of epileptics require careful attention. Copious drinking of 
water is an aid to this end. Epileptics need to be trained in 
habits of cleanliness and order. Most of them can be taught 
some useful occupation, thus giving their activity an outlet. 
Outdoor labor is especially beneficial in reducing the number of 
attacks and in lessening deterioration. Much can be done to 
inculcate self-restraint. We need constantly to bear in mind 
to safeguard epileptics from injury, and all occupations and 
amusements must be selected with this in view. Epileptics 
must not be allowed to climb stepladders, nor to go alone near 
bodies of water, or near machinery. In their training, patience 
is a virtue constantly in demand. They need to be under close 
supervision at night, to guard against suffocation after a con- 
vulsion, in case they should so turn as to lie upon the face while 
unconscious. All sources of local irritation should be removed 
if possible. Attention to the eyes, the teeth, the nasal cavities, 
the genitals, and the bowels is very important. 

In an epileptic attack the patient should be prevented from 
falling, if possible, and lowered to the floor ; or, if already fallen, 
should be moved to a place of safety if he is where he can be 
burned or otherwise harmed. The clothing is to be loosened 
about the neck, the tongue protected, a pillow placed under the 
head, and the patient prevented from injuring himself; other- 
wise he is to be let alone and allowed to sleep, if he will, after- 
ward. 

The nurse in care of epileptic patients should keep a record of 
every convulsion until requested to discontinue it. This record 
should describe the nature of the aura, its duration, the part of 
the body first subjected to convulsions, then the order in which 
the parts are in turn affected; the stage when consciousness is 
lost, the condition of the pupils, the duration of the tonic and 



374 NUKSING THE INSANE [Chap. XXVII 

clonic contractions, and of the coma, and a description of the 
after symptoms. 

In status epilepticus prolonged hot baths are sometimes of 
benefit. Compression of the carotid arteries is also employed 
if arterial tension is very high. 

Some one has said that neurasthenia is a disease of the 
over-employed, and that hysteria is a disease of the unem- 
ployed. In this statement we have a hint as to what to do for 
hysterical patients. Get them interested and occupied. At the 
same time teach them moderation, especially in the emotional 
field. At first, in order to correct errors of habit and environ- 
ment, they will need to be removed from annoying surroundings, 
and trained to a certain routine in their physical and mental life; 
but as treatment progresses, they must be trained to ignore 
irritating stimuli. They must learn to grasp the philosophy of 
"grin and bear it," and must be stimulated to a certain pride in 
feeling that they are no longer shorn lambs that need the wind 
tempered for them; but that they can acquire a certain poise and 
stability that will enable them not only to withstand but to help 
others less strong to cope with their difficulties. 

When hysterical persons learn that hypersensitiveness is only 
another name for misery, and that much of what they call 
" temperament " is only ill-regulated emotional control, they 
will not be so proud of their impressionable make-ups. They 
will really desire to train this passionate sensitiveness into 
strength and calm. 

If these patients are in need of bodily upbuilding, the " rest 
cure " may be called into use ; but in many cases just the oppo- 
site treatment is requisite. 

The rest cure, generally speaking, consists of rest in bed, 
isolation from friends, the prohibition even of letters, over-feed- 
ing, combined with hydrotherapy, electricity, and massage. 
Later, exercise, diversion, and occupation as prescribed by the 
physician. Throughout the treatment the patient and judi- 
cious efforts of nurse and physician are of the utmost impor- 
tance. One often has to combat the erroneous notion that 
patients lose strength from lying in bed; that milk does not 
agree with the patient; that the bowels will not move without 



Chap. XXVII] NURSING IN VARIOUS FORMS 375 

cathartics, and other notions that the wise physician will know 
how to deal with, but in which he must be seconded by the nurse. 
Patients taking the modified rest cure even should not be allowed 
to read in bed, although they may be read to, and may look at 
illustrated magazines if the physician allows these diversions. 

During convulsive attacks the seizures can sometimes be cut 
short by exerting pressure upon certain parts of the body ; for 
example, the ovarian region. Or a dash of cold water in the face, 
or a sharp command, may serve to dispel morbid symptoms. 

Among the hydrotherapic measures, cold spinal douches, or 
alternate hot and cold spinal douches are of the most value. 

Hysterical patients may make many threats and " fake " 
attempts at suicide, but even such attempts may result fatally 
from miscalculation or bad management on the patient's part. 
It is desirable that patients with these proclivities be prevented 
from obtaining means for making even " fake " attempts at 
suicide. Reports concerning the hysterical patient should never 
be made in her presence. 

It must be remembered that although hysterical and neu- 
rasthenic patients are inclined to exaggerate their complaints, 
there may be times when they have unmistakable symptoms 
demanding attention. We must not overlook these conditions 
because of their hypochondrical tendencies. 

In the treatment of the various neurasthenic and psychas- 
thenic states, we need to remember that in most of these 
patients a constitutional weakness of the nervous system, and 
a faulty education and training, are at the root of the matter. 
The efforts to help them are, therefore, largely on educational 
lines. We must build up the body if it needs building up, fur- 
nish as favorable an environment as possible, teach the patients 
the importance of self-control, the value and dignity of labor, 
and the danger of alcohol and drugs to all neurotic persons. 

It is difficult to lay down rules for the treatment of these cases, 
as each one requires careful personal study, and a course of life 
laid out and persisted in according to its individual needs. 

In cases of overwork we may need to take the matter in hand 
peremptorily if the patient is so chained to his work that he will 
not give it up. One cannot be in the show and see it too, and the 



376 NURSING THE INSANE [Chap. XXVII 

person who is overworked, and pushed on by a morbid desire for 
activity, is often the least capable of seeing that he is going beyond 
his strength. 

It is sometimes difficult to distinguish between true exhaustion 
and an exaggerated sense of fatigue really induced by the patient's 
habit of getting tired. This habit of tiring on the slightest exertion 
(some call it laziness) is a fault of character, rather than an 
evidence of ill health. Such persons need to be taught not to 
nurse their susceptibility in this direction. We are all in reality 
stronger than we think we are, but by thinking ourselves less 
strong than we are we become less strong. We make suggestions 
to ourselves that we are tired, and behold, we are tired. One of 
the ways of helping a person who is given to harmful suggestions 
would be to talk to him somewhat in this way : — 

"You have made a mental representation of your trouble and 
are trying to live up to it. You are keeping it alive by con- 
stantly picturing it to yourself. You are like an actor who is 
playing a part, and you are playing it so well that you have for- 
gotten that it is not real. If a real actor, playing the part of 
a man who is to stab himself, should lose his head, he might 
really do the deed. We have to prevent you from such con- 
sequences, and show you that you must not stab yourself with 
the dagger of the imagination. You must be patiently led 
out of the state of self-deception. Your auto-suggestions coun- 
teract the healthy suggestions one can give you. By repeating 
these suggestions to yourself often enough they tend to become 
fixed. Your mental representations, unrestrained by reason, 
have acquired incredible acuteness, so that you view everything 
about yourself in a distorted way. Your reason is lame, it limps. 
It must lean on me for a crutch till it gets strong again." 

It is in some such ways as this that the physician may talk 
to certain patients, and it is well for the nurse to have an intel- 
ligent appreciation of the line along which the psychic treatment 
is being pushed, although as a rule in all these cases it is better 
to leave the physician and patient by themselves while such 
talks are going on, as the mere presence of the nurse is likely 
to prove distracting or embarrassing to the patient. 

The truth of auto-suggestion was long ago stated in the Scrip- 



Chap. XXVII] NURSING IN VARIOUS FORMS 377 

tures: "As he thinketh in his heart so is he." Realizing that 
a certain thing from which a person suffers is due to his auto- 
suggestion should not make us any the less sympathetic with 
him ; the fact that the origin of the suffering is in himself does 
not lessen the suffering. What we need to do is to help him 
overcome his unfavorable self-suggestions. 

We need, then, to teach patients not to attend to depressing 
thoughts, feelings of fatigue, compulsive ideas, and so on. Tell 
them they are wiser when asleep than when awake, for in sleep 
though we sense annoying things (for example, noises), we fail 
to attend to them, and sleep on; something of this ignoring may 
be cultivated in our waking state by refusing attention to 
irritating stimuli. The cases are of course not exactly parallel, 
but one can work on and perhaps get absorbed in one's work, 
and so learn to forget feelings of fatigue, or depression, and the 
like, as unworthy of attention. 

In some of the cases of morbid fears, the fear almost paralyzes 
the patient so far as action is concerned. It is a well-known fact 
that if a person is hypnotized, one drawing a chalk line on the 
floor can, by merely saying to the hypnotized person, "You 
cannot step over that line," so affect him that he is powerless 
to step over the chalk mark, yet his actual muscular power is no 
whit impaired. A patient may fear that he cannot sleep, that 
he cannot attend church without fainting, and may have other 
groundless fears. His belief or fear that he cannot sleep is the 
chalk line he must step over, and he can do it as soon as he will 
let go the belief that he cannot step over it. 

Many of these psychasthenic cases are beset by countless 
doubts — doubts as to whether they have locked a door, posted 
a letter, made themselves understood, or perhaps as to whether 
they have been immodest, or have injured some one, and when 
they once begin to doubt, the doubt crowds out everything else, 
and makes them unfit for anything. A bit of nonsense rhyme 
in a recent popular book illustrates this aptly: — 

" The centipede was happy quite 
Until the frog for fun 
Said, l Pray, which leg comes after which ? ' 
Which wrought the mind to such a pitch 



378 NURSING THE INSANE [Chap. XXVII 

He lay distracted in a ditch, 
Considering how to run." 

Some of these patients tormented by compulsive ideas need 
tonic treatment, cold rubs, and sprays, forced feeding and good 
nursing, and when these have done their work the doubts and 
imperative ideas subside into the background. In other cases 
the morbid symptoms persist after the body has been brought 
to a seemingly normal state of health. 

Nothing quiets patients with phobias, or morbid fears, like 
the frequently repeated statements that they will not succumb 
to their fears, and that as they get stronger they will be able to 
lose sight of what so disturbs them now ; in other words, that 
they will forget they have a hundred feet, and will just run. 

In all these attempts to drive away annoying thoughts, or 
to dispel annoying moods, or to break up undesirable habits, 
we must remember that the effort of the will will not do it, but 
that new and absorbing interests and habits will do it by 
substitution. 

In trying to conquer the habit of masturbation where the 
patient wishes to conquer it and will cooperate, teach him that 
it is not to be done by saying to himself that he will annihilate 
the physical in himself. That is folly. He cannot annihilate 
what is so ingrained, and what is wisely ordained as a part of his 
very self. He must learn to dignify the physical. Accord to it 
the proper place in his life. As has often been pointed out, 
many a monk in the desert has kept his attention fatally fixed 
upon the physical by vowing that he would annihilate it. 

Neurasthenics and psychasthenics have what we may call 
an overplus of frictional qualities in their relationship with 
people. In other words, being hypersensitive, and living in 
their sensations too much, they keep themselves keyed up so 
high that every relation in life, every experience, furnishes undue 
excitation, everything enjoyed is enjoyed too keenly, everything 
suffered is suffered too keenly. 

Discouragement at the slow progress in these cases may be 
met by pointing out to the patients the symptoms which have 
disappeared. Teach them to dwell on the thought that these 
have gone, rather than upon that that the others remain, but 



Chap. XXVII] NURSING IN VAEIOUS FORMS 379 

beware of too much encouragement. What is said should be 
said in a few words, judiciously, in the patient's presence, but 
perhaps addressed to another rather than to himself. In this 
way the patient is put under no obligation to reason and is given 
no chance to resist the statements, but is merely given a true 
statement as to the facts of the situation, and a glimpse into 
the possibilities of adjusting himself in the future to the situa- 
tions that are at the time so difficult for him. No attempt 
should be made to force him to the right way of thinking ; simply 
furnish him the material for a correct adjustment, and when 
the time comes he will be able to use the hints that have been 
judiciously dropped in his hearing. 

Hold the thought of health before your patients as something 
just ahead of them to be reached out after and worked toward. 
Make light of their indispositions, not in the sense of neglecting 
to report them, nor of neglecting to seek to relieve them, but 
help the patient to see over and beyond them as trivial inter- 
ruptions in the path to health, not as obstacles in arresting 
progress. Never tell your patients that their troubles are 
imaginary. If the physician thinks it wise to do this, that is 
another matter. 

Cases of Idiocy and Imbecility are not properly subjects for 
care in an insane hospital, except when an attack of insanity, 
in the case of an imbecile, supervenes. These defectives should 
early be placed in institutions equipped for their care and train- 
ing. In such institutions some idiots can be taught to talk a 
little, to stand, walk, move, and dress, and care for themselves 
to some extent. The senses are trained so that these unfortu- 
nates learn to perceive some things and to attain some ability 
of expression. Those who are susceptible of it are taught 
games, music, manual labor of various kinds, and some imbeciles 
of the higher grades learn useful trades, and show surprising 
skill in certain things. All can be helped to form good habits, 
and to acquire some degree of self-control, thus preventing 
or at least lessening the dangerous assaults upon others. 
Alcohol must be prohibited in these cases. 



CHAPTER XXVIII 

NURSING THE INSANE IN PRIVATE HOUSEHOLDS AND SANITARIA 

The nurse who undertakes to care for the insane in private 
households needs to be even more thoroughly equipped than 
one who is surrounded by the conveniences, the means of safe- 
guarding the patient, and the moral support of a State hospital. 
Her resourcefulness and tact, as in private general nursing, are 
more frequently put to the test than they can ever be in hospital 
nursing. Clear reasoning, sound judgment, and readiness in 
action are indispensable qualities. 

There is but little that can be said in favor of home treatment 
for the insane, and a great deal that could be said against it. 
In favor of it we may say that in exceptional families, and under 
certain favorable conditions, admitting of isolation from the 
household, yet securing for the patient the comforts and luxuries 
of a home, it may seem advantageous to try home treatment, 
but the cases where this fortuitous combination can be found 
are exceedingly rare. Against home treatment we may cite the 
following conditions to be contended with: The patient can 
rarely be isolated from his family, yet isolation is conceded to 
be one of the most important factors in treatment; not isolation 
from the family alone but from friends and neighbors, and separa- 
tion as well from the scenes and associations in the midst of 
which morbid symptoms developed. Even if the members of 
the family are well poised, calm, and judicious, still isolation is 
desirable, and if, as happens in most families where insanity 
develops, there are other members who are "high strung," 
unduly impressionable, and neurotic, the influence is most 
pernicious both on the patient and on the other members of the 
household. Usually the more neurotic and unfit the friends 
are to be helpful to the patient, the more such persons insist 

380 



Chap. XXVIII] NURSING IN PRIVATE HOUSEHOLDS 381 

that they are the very ones to direct and help to influence him, 
to plead with, or argue, or ridicule, or coerce him into normal 
behavior. A nurse who is confronted by the task of attempting 
to care for a patient in such a household is indeed to be pitied, 
for without intending to do it, and without knowing that they 
do it, the relatives thwart her efforts at every turn. Added to 
this is the fact that the patient is, as a rule, much more of a tyrant 
in his own household than he would be in an institution, and 
will by hook or crook gain his ends, disturb the household's 
routine, cause constant friction, overrule the friends even when 
they mean to be firm, try their patience till they sometimes feel 
themselves on the verge of a breakdown, and in countless ways 
will prove not only a disturbing influence in the family life, but 
will, by reason of the unavoidable antagonisms engendered, 
lessen his chances for recovery. 

It is only fair to consider the good of the many, as well as the 
question of depriving one person of his liberty, and one insane 
person in a family can, by his vagaries and his conduct, so upset 
the entire household that permanent harm is done to other 
impressionable members. It may not result in causing them 
to become insane, but may act in various other harmful ways; 
in young and imitative children it may exert a most pernicious 
influence ; in sensitive and sympathetic persons it may cause 
sleeplessness, and other symptoms of ill health, and may partially 
or wholly incapacitate them for work, often at a time when 
much is depending upon the quality of their work; in the aged 
the extra strain may increase arterial changes and bring about 
mental instability and an earlier decay than would otherwise 
appear. These are only a few of the baneful effects of attempt- 
ing home treatment. 

Then, too, it is difficult to get nurses outside of hospitals for 
the insane who are fitted by training to care for mental invalids, 
however thorough their training has been in other branches of 
nursing. Furthermore, it is rare to find the family physician 
sufficiently versed in directing the treatment of such cases to 
make him willing to undertake them. Certain branches of 
medicine require special experience and practice ; surgery is 
one of these, mental medicine is another. Skill can only be 



382 NURSING THE INSANE [Chap. XXVIII 

acquired by long training in these special lines, and the busy- 
general practitioner seldom has the time to acquire even a the- 
oretical knowledge of mental diseases, such as could be obtained 
from the literature on the subject, to say nothing of his lack of 
first-hand knowledge of actual cases. 

Another strong reason against home treatment is the poor 
facilities it offers for guarding against suicide, destruction of 
property, injury to others, and intentional or unintentional es- 
cape or wandering from home. Especially important is it that 
patients with suicidal or hysterical tendencies, drug or alcoholic 
habitues, and excited and violent patients, be removed from 
home care to a properly equipped sanitarium, or to a State 
hospital. 

In the State hospitals especially, the patient experiences at 
once the wholesome discipline that comes from rinding himself 
one of many, instead of the center of attraction. He immediately 
has a new outlet for his thoughts, and many of his morbid ones 
get pushed aside or crowded out just because of the multitude of 
new impressions made upon him. He soon sees that he is part 
of a big machine, that law and order prevail here, and that the 
individuals — patients, nurses, and physicians — have to con- 
form to certain established rules. This is much less galling than 
to have to submit to rules laid down for him as an individual, 
and he is less likely to chafe under them than he is under rules 
enforced by physician or nurse in his own home. Seeing other 
disturbed patients is often conducive to self-control, and getting 
an insight into their absurd beliefs and irrational conduct often 
has its corrective influence upon his own beliefs and behavior. 
The kind but firm and understanding attitude of nurses and 
physicians who treat him as a sick man and not as a culprit, has 
a steadying and soothing effect upon him, and the absence of 
the anxiety of doting relatives is a most salutary part of the 
treatment. Relatives can seldom learn that the "watched pot 
never boils," and find it hard to wait for results that must 
of necessity come gradually. For this reason it is better for 
them, as a rule, and far better for the patient, that they meet 
only at rare intervals during the course of an acute attack. 
Every alienist can point to cases whose recoveries were seriously 



Chap. XXVIII] NURSING IN PRIVATE HOUSEHOLDS 383 

prejudiced and convalescence unnecessarily prolonged, and some 
which he has every reason to believe have been irreparably 
injured, by the obstinate insistence of relatives in visiting the 
patient when he was just at a critical stage where the sight of 
the relatives, and all that this would call up, was just enough to 
turn the case on the downward instead of the upward course. 

Home Nursing. — If a nurse does have to care for a patient in 
his home, there are many things, as before hinted at, that she 
will need to consider. She needs to be thoroughly equipped for 
general nursing, and for the special nursing of these cases — 
matters already treated elsewhere in this book. 

The sanitary arrangements need to be looked after; the choice 
of the room or rooms occupied by the patient and the nurse, 
are important considerations; the means for protection from 
fire, from escape, and from danger to the patient, and to the 
nurse, are of the utmost importance. Constant vigilance night 
and day in certain cases is imperative, and only a nurse of wide 
experience can determine in what cases such vigilance may be 
relaxed. Some patients that an untrained observer would 
least suspect are the ones requiring the most thorough surveil- 
lance. All medicines and appliances by which the patient could 
do harm to himself or others must be kept under lock and key. 
Matches, gas jets, lighted lamps, and razors are continual sources 
of danger. The windows must be securely guarded, or so ar- 
ranged that they can be raised only six inches, doors kept 
locked and the keys in charge of the nurse. A window pane, 
a tumbler, or a mirror which can be broken at one blow will 
furnish ample means for self-destruction, and it can all be done 
so quickly that help, though speedily summoned, comes too late. 
Patients are often very fertile in attempts at escape and 
at suicide; a pair of nail scissors or a razor can cause fatal 
hemorrhage, though the patient has only a few moments in which 
to act ; a twisted nightgown or sheet and something strong 
enough to hang from are all one needs to strangle one's self, and 
a patient intent on drowning could do so in a basin of water. 

Bolts should be removed from the doors of rooms to which 
the patient has access, else he may lock himself in a bathroom, 
for example, and do great mischief or harm to himself, while the 



384 NURSING THE INSANE [Chap. XXVIII 

nurse stands helplessly pounding and entreating on the other 
side of the door. 

The room where the patient is to stay should be large, airy, 
cheerful; as quiet as possible, with a pleasant outlook, if it 
can be arranged; simply furnished, with but few unnecessary 
things; this last requirement, not only to avoid cluttering and 
the unrestful feeling of over-furnished rooms, but also to reduce 
the number of things to be cared for, and to be used as weapons, 
or to be destroyed, in cases where the patient is violent or de- 
structive. The walls of the room should be restful; if possible, 
painted or papered with a cheerful quiet color, and free from 
intricate or tiresome design. Pictures should be few and well 
chosen. In destructive cases it is sometimes well to procure 
cheap unframed prints, reproductions of good pictures, and 
vary these from time to time. Books, magazines, and music 
may be furnished according to the nature of the case, and the 
circumstances of the family. Plants and flowers simply and 
tastefully arranged are almost always acceptable. Bare floors 
with a few rugs are preferable to carpets and in the case of 
unclean patients are almost indispensable. 

A screen, a lounge, and an easy chair or two, but not a rocker, 
a bedside stand, or a bed tray, and a commode, are some of the 
things likely to be needed in most any case of extended nursing. 

The nurse will make her value and ability distinctly felt if she 
shows herself capable of adapting things already at hand to her 
use, rather than to call upon the family to provide this and that 
convenience to which she has been accustomed in hospital work. 

She needs to be considerate of the domestics but not fa- 
miliar with them, considerate also of the tastes, customs, and 
weaknesses of the members of the household; she needs to 
make them feel that she has come in their midst as a helper, 
not as one who increases the work and the difficulties under 
which all are laboring. No nurse worthy of the name will 
divulge to others matters of which she learns in her profession. 

She should see that her vigilance over the patient is as unob- 
trusive as she can make it so as to reduce as much as possible 
chafing under restraint. It is important that the patient 
feel the utmost confidence in her kindness, courage, and sincerity. 



Chap. XXVIII] NURSING IN PRIVATE HOUSEHOLDS 385 

If the patient feels that he can impose upon the nurse in any way, 
or that she is afraid of him, or that she is not to be depended 
upon, it is disastrous to her influence over him. 

It is often annoying to a patient to have the nurse carry on 
whispered conversations or to talk in a low tone in the room or 
outside the door with the physician or others; if the patient 
learns that the nurse meets the physician in some other part of 
the house, his suspicions may also be aroused. It is well in 
many cases to leave a note downstairs to be given to the doctor 
on his arrival, informing him of important conditions and hap- 
penings, and so obviate the patient's suspicions. 

The nurse needs to be prepared for the unexpected at every 
turn in dealing with the insane, yet her own work must be carried 
on with reference to a well-thought-out plan that takes into 
consideration the physician's directions, the nature of the case 
and of the environment, the convenience of the other members 
of the household, and the degree of help that she can count on 
in the other members. By her own method and calmness, and 
dignified but tactful authority, she can, as a rule, get the most 
confused household into its accustomed orderly routine, make 
friends with her patient, and get his cooperation, and can so 
win the respect and confidence of all concerned that they are 
willing to leave her and the physician to manage the case. 

She should so educate the household that they do not require 
her to talk about the patient. They must learn to cultivate at 
least an assumed indifference, for it is extremely wearing on 
a nurse in the few minutes that she gets away from her patient, 
from time to time, to be obliged to discuss his manifestations and 
his progress or lack of progress. This is not saying that she is to 
be so reticent as to render the friends dissatisfied with her ser- 
vices. No rules can be laid down for these things. This is only 
one of the many instances where tact and discretion are needed. 

It will be necessary to enlist the aid of domestics or of other 
members of the household occasionally, unless two nurses are 
provided; in doing so, be particular to select those most con- 
genial to the patient. It can only aggravate his symptoms to 
bring into his presence those toward whom he feels antipathy, 
even if it is only a temporary antipathy. 

2c 



386 NURSING THE INSANE [Chap. XXVIII 

In addition to the rules for nursing already laid down elsewhere 
in this book, the nurse is here reminded briefly of some of the 
things to be remembered in the various mental disorders she 
may be called upon to treat. She should, of course, look after 
the bodily health of her patient, observe and report carefully 
concerning all symptoms whether physical or mental, and 
should follow the physician's directions implicitly, except in 
some unexpected complication arising which requires that 
she act according to her best judgment, even if contrary to 
general rules outlined by the physician. In such cases, how- 
ever, she should notify the physician promptly of the facts 
in the case. 

Excited patients are usually mischievous, noisy, loquacious, 
and violent; they need close supervision; they are changeable 
in mood and can often be diverted by ready wit and tactful 
handling, and by yielding to them in non-essentials. Prevent 
accidents by foresight, avoid angry outbreaks by your own good 
humor, forbearance, and friendliness. Never attempt to gain 
your point by deception or by false promises, but avoid unneces- 
sary issues that are known to increase the patient's excitement. 

Depressed cases need the closest scrutiny, even if no suicidal 
threats or attempts have been made. All means which might 
suggest suicide should be kept out of sight. Such patients are 
to be kindly dealt with, but expressed sympathy in so many 
words should be sparingly used; it only aggravates their condition. 
Appearing to ignore their complaints is often wholesome treat- 
ment, and your efforts should be directed largely toward quietly 
furnishing other food for thought without their realizing that 
you are trying to divert them. They should be kept from self- 
mutilation also, such as picking the face and pulling out the hair. 

Exhausted patients need to be generously fed, and need to 
have the most judicious care to conserve every bit of strength 
they have. Baths and other means to promote sleep are im- 
portant parts of the treatment. 

Puerperal patients need especial care to prevent them from 
injuring themselves or the baby, provided that it is allowed to 
be kept near the mother, which is seldom advisable. 

General paretics need supervision to prevent injuries from their 



Chap. XXVIII] NURSING IN PRIVATE HOUSEHOLDS 387 

clumsiness and increasing weakness, and from choking while 
eating; in the later stages of this disease it is very necessary to 
guard against bed sores. 

Epileptics need supervision to keep them from falling against 
or into things that would seriously injure them; also to prevent 
their injuring others between paroxysms. They must be care- 
fully watched when eating, lest they bolt their food. 

Delirious cases of all kinds require continual care, quiet, baths, 
and diet as ordered. In most patients with delirium a darkened 
room and the reduction of all sensory impressions to a minimum 
are needed, but in some patients with delirium tremens distressing 
hallucinations are relieved, as a rule, if a light is allowed in the 
room. The near presence of the nurse, and her quiet frequent 
reassurance are very helpful to patients so afflicted. Do not 
restrain such patients on any account. 

Senile subjects are especially trying because of their restlessness, 
usually more marked at night, their uncleanly habits, and their 
continual desire to go home even when they are at home. They 
will wander away aimlessly unless prevented. They do not 
yield to argument or persuasion. A physician now in charge 
of one of our State hospitals once told me how in the early days 
of his care of the insane, when, as a medical student, he was 
acting as nurse to a senile patient in his home, he managed 
to humor the patient repeatedly in his frequent requests to be 
allowed to go home, and at the same time get him to take a fair 
amount of daily exercise out of doors. When the patient's 
entreaties to go home would be persisted in, his nurse would 
say, "Well, let's go," and out they would start down the street, 
letting the patient's inclination direct their course. After 
sufficient distance had been traversed, the nurse would suddenly 
halt, divert the patient by calling his attention to some building 
or other object of interest near by, and in the course of the halt 
would so manage it that they turned around, so that on starting 
up again, they were facing toward home without the patient's 
having noticed the fact. On retracing their steps, and nearing 
the home, familiar landmarks were casually called to the patient's 
notice, and on arriving at his own door he would usually be paci- 
fied, recognizing it momentarily as home, and then, as a rule, 



388 NURSING THE INSANE [Chap. XXVIII 

being sufficiently wearied by his exercise to be willing to rest for 
a time. Such a course could only be used in senile cases, of 
course, but it is an instance of the tact that may be practised 
in such cases. Baths, packs, and other measures noted in the 
chapter concerning sleeplessness, are useful in caring for senile 
patients. 

Forced feeding and other special nursing measures are only 
resorted to on advice of the physician. Occupation, amuse- 
ment, and out-door exercise are prescribed by the physician. 

There are certain cases of nervous and mental disease some- 
times called Borderland Cases that are treated successfully in 
their homes if nurse and physician possess the requisite skill 
and resourcefulness so to treat them, and if the friends can be 
kept entirely away from the patient. In such cases medicine 
and even general nursing play a very small part; the personality 
of nurse and physician count for almost everything. A nurse 
for such patients requires refinement and tact to a considerable 
degree, broad interests and sufficient education to make her 
an agreeable companion for her patient who is thrown so ex- 
clusively upon her society. 

Nursing in Sanitaria. — Nursing of patients in Sanitaria differs 
but little from that in our State hospitals. In the licensed sani- 
taria the means for protection and the system of espionage 
are sufficient, as a rule, to relieve the nurse from the anxiety 
she feels in nursing in private houses devoid of these safe- 
guards. There is, however, more need of vigilance than in the 
State hospitals. 

In a general way we may say that nursing in sanitaria differs 
chiefly from the larger part of nursing in the State hospitals, 
in that the patients are all private in sanitaria, come from the 
more affluent and better-bred classes, and are more exacting 
and fastidious as to the little things and the niceties of life than 
are many of your public charges. They are paying for more 
attention, more comforts, and more luxuries, and even if they 
themselves do not exact them, their friends usually will, and it 
is only fair that they receive what they are supposed to receive 
when their friends place them in these private institutions. 
Nurses who care for patients in these institutions are therefore of 



Chap. XXVIII] NURSING IN PRIVATE HOUSEHOLDS 389 

value in the degree to which they are capable of ministering to 
the social and psychic needs of their patients, as well as to their 
bodily needs, and who are conscientious and painstaking to see 
that their patients get the benefits of the care their friends are 
trying to secure for them. 



CHAPTER XXIX 

MISCELLANY 

Requirements for the Commitment of the Insane to State 
Hospitals. — The commitment of an insane person must be made 
out on regular blanks provided for the purpose by the State 
Commission in Lunacy. These blanks may be obtained on 
application from the office of the Commission in Albany, or from 
County Clerks, Superintendents of the Poor, Commissioners of 
Charities, from any of the New York State hospitals, and, 
usually, from physicians who are legally qualified examiners in 
lunacy. Any physician in good standing, a graduate of an in- 
corporated medical college, who has been in practice three years, 
and who has filled out a prescribed blank showing his qualifica- 
tions in this respect, and filed in the Commissioners' office in 
Albany a certified copy of the certificate of a judge of a court 
of record, is a legally qualified examiner in lunacy. 

The first thing to do in attempting to get an insane person 
committed is to find out whether the family physician is a 
qualified examiner in lunacy. If he is, he will explain the other 
necessary steps to take ; if he is not, he will probably be able to 
name two other physicians who are legally qualified, and who 
will be able to counsel the friends further. 

The essential steps in the procedure are as follows: — 

A petition must be made to a judge or justice of the county 
court, or of the Supreme Court; it must be made on the prescribed 
blanks, and must set forth clearly the reasons for believing 
that the person in question is insane, and also those which lead 
you to ask that an order for his commitment be granted. 

This petition may be made by any one with whom the alleged 
insane person may reside, or at whose house he may be, or by 
the father, mother, husband, wife, brother, sister, or the child, 
of any such person, or by any overseer of the poor, or a super- 

390 



Chap. XXIX] MISCELLANY 391 

intendent of the poor of the county in which any such person 
may be. 

This petition must be acccompanied by the certificate of 
lunacy made out by two qualified physicians who have jointly 
examined the case, and it must be within ten days next before 
the granting of the judge's order. 

The law also provides that a notice stating that such an applica- 
tion is about to be made, be served personally at least one day 
before making said application upon the person alleged to be 
insane, or, in case the one who makes the petition is an overseer 
or a superintendent of the poor, notice must be also served upon 
the husband or wife, father or mother, or next of kin, of the alleged 
insane person, if there be such known to be residing within the 
county, and, if not, upon the person at whose house the alleged 
insane person may be. This part of the law, however, may be 
waived by the judge, if he thinks the proof adduced is such that 
the patient is unquestionably insane and in need of hospital 
care, and especially if in the opinion of the physicians, the notice 
would be injurious to him by unduly exciting and alarming him, 
or if, for any other good reason, it seems best to dispense with 
personal service. Or, he may, instead of requiring personal 
service, direct that notice be served upon some near and re- 
sponsible relative. 

The judge may demand a hearing upon his own motion or 
upon the request for the same by the alleged insane person him- 
self, or any of his relatives, or a near friend who asks for it in 
behalf of the alleged insane person. He may then examine the 
person alleged to be insane, and take the testimony bearing on 
the case, and, according to his findings, discharge or commit the 
person as he sees fit. 

If he sign the order of commitment, the superintendent of 
the hospital to which the patient is committed is then to be 
notified of the fact, so that provision may be made at once for 
the transportation of the patient. 

The blanks for the petition, for the certificate of the physicians, 
for the judge's order, and for the other matters mentioned, are 
all bound together in one compact pamphlet that, as has been 
said, may be had on application at the places previously named. 



392 NURSING THE INSANE [Chap. XXIX 

The certificate is outlawed if five days have elapsed from and 
inclusive of the date of the judge's order, before the patient is 
conveyed to the hospital to which he has been committed. 

The commitment papers must be presented to the super- 
intendent, or to the person in charge of the institution, before 
or at the time that the patient is brought to the institution. 

The costs of commitment of a poor or indigent person, and 
the expense of providing proper clothing, shall be a charge upon 
the town, city, or county securing the commitment. In the 
case of persons not poor or indigent, the costs are charged to 
his estate or are met by persons liable for his maintenance. 

Emergency Cases. — If a case be particularly urgent, and re- 
quire immediate hospital care, there is a provision in the law 
whereby the insane person can be temporarily admitted to the 
hospital if accompanied by the petition and the physicians' med- 
ical certificate. Meanwhile prompt steps must be taken to 
secure the judge's order, as before explained. The patient may 
be detained at the hospital five days, pending the judge's order 
of commitment, but in order to do this, the petition and the cer- 
tificate of lunacy, and the patient's condition itself, must clearly 
prove such a procedure necessary. 

With these rigid precautions that the Insanity Law makes 
obligatory, it is easily seen how improbable it is that persons 
not insane can be committed to hospitals for the insane. 
Troublesome as these requirements are to carry out, a little 
reflection will enable one to see the wisdom of safeguards that 
provide against the unjust commitment of any one to our State 
hospitals, or his unjust detention therein. 

Clothing of Patients. — Public patients are required to be 
dressed in a new suit of apparel throughout when brought from 
a jail or an almshouse, but when brought from their homes this 
requirement need not be rigidly enforced by the attendant, if 
he finds on examination of the clothing owned by the patient 
that it is clean and suitable, and that there is no apparent danger 
to be feared from contagion of any kind. Between the last day 
of October and the first day of March a shawl, cloak, or over- 






Chap. XXIX] MISCELLANY 393 

coat, and gloves or mittens must also be provided. This 
clothing must be furnished by the county from which patients 
are committed, unless provided by their friends. 

Conveyance of Insane Patients to State Hospitals. — When 
nurses or attendants are sent to convey patients to the hospital 
they need to get explicit directions as to where they are to go and 
for whom, and what trains, roads, changes, and means of trans- 
portation they are to depend upon, both for going and returning. 
They need to get from the steward sufficient money to defray 
the probable expenses, and to keep an itemized account of all 
expenses incurred and turn in the same on their return. 

They should be plainly and neatly dressed and should on all 
occasions seek to make their demeanor and way of meeting 
trying situations such as will reflect credit on themselves and on 
the hospital they represent. 

On arriving at the place where the patient is sojourning, they 
are first to inquire for the certificate, and are to ascertain whether 
the commitment is legal or not. It is not legal (1) if five days 
have expired from and inclusive of the date of the judge's order; 
(2) if the date of the judge's order is more than ten days after the 
date of the medical examination, counting the day of examination 
as one day. 

If the nurse ic satisfied that the commitment is legal, she is 
then to see the patient, and a responsible relative or friend from 
whom she is to inquire briefly concerning the mode of onset, 
and the manifestations that led to the commitment. In some 
hospitals it is customary to send a pamphlet to the friends of 
patients, giving information likely to be needed by them, and 
in turn telling them what information is likely to be needed by 
the physicians, to insure a proper understanding of the case. One 
of these pamphlets, when provided, is taken by the nurse, and its 
use explained, and the friends are asked to visit the hospital, if 
practicable, within a few days, or to send the family and personal 
history and onset of the disorder by letter at their earliest con- 
venience. If the nurse makes any inquiries herself, as will some- 
times seem prudent to do, she should take care not to offend by 
what would seem curious or impertinent questions. 



394 NURSING THE INSANE [Chap. XXIX 

If the patient is in an almshouse, and this fact was not known 
before leaving the hospital, the nurse is to communicate by- 
telephone or telegraph with the hospital before bringing the 
patient. She is also to do this if the patient is over sixty 
years of age, or has been feeble-minded since childhood, or is 
in what seems to the nurse too critical a condition to be 
moved, or is unmistakably not insane. Patients with conta- 
gious diseases are on no account to be brought to the hospital. 
She may also refuse to take the patient if the patient is not 
clean, and if suitable clothing is not provided. As a matter 
of fact, however, many a nurse accustomed to caring for this 
class of patients can go into a home where all is confusion 
and where the friends seem utterly unable to render the patient 
clean and tidy, and can soon put her in a proper condition; and 
while this is not required of the nurse, most nurses are humane 
enough to prefer to do it rather than leave the friends in the 
lurch, and incur the extra expense of returning to the hospital 
until the patient's body and clothing are suitably prepared, or 
to sit around idly waiting while the friends attempt to do work 
that she could at least lighten by a helping hand. 

If the near relatives seriously object to the removal of the 
patient, it is well to communicate with the hospital before insist- 
ing on the removal. 

The patient should leave his money and valuable jewelry at 
home; wedding rings as a rule may be allowed, and the patient 
may also be allowed to bring a dollar or two of pin money if so 
desired. If the friends wish more money or valuable belongings 
to accompany the patient, it must be made clear that it is done 
at their risk. The nurse should give the patient's friends the 
name and address of the superintendent of the hospital, to whom 
all letters of inquiry are to be addressed, but should make them 
understand that they may communicate directly with the patient. 
The name, address, and relationship of the nearest relative as 
correspondent is to be secured by the nurse. 

The nurse's manner of approaching and greeting the patient 
should be quiet, friendly, sincere, and tactful. Patients are 
quick to detect insincerity, palaver, indifference, or unkindness; 
but if approached in the right way the instances are compara- 



Chap. XXIX] MISCELLANY 395 

tively few where an experienced attendant cannot mollify iras- 
cible ones, overcome resistance, and persuade the patient, since 
it seems best to take this step, to come willingly, or at least 
unresistingly, to the hospital. 

There will be occasional cases where persuasion and tact are 
unavailing. Such must be dealt with by firmness, unvarying 
kindness, and if necessary by force, never by deception. You 
will have to combat this tendency to deception in the friends. 
They often have an elaborate scheme arranged for deceiving the 
patient, sometimes one in which the family physician even has 
connived, but your duty is clear. You must not be a party to 
such deception. You are to explain to the patient as tactfully 
as you can that she is ill, if not in body, then in mind; and that 
a hospital for just such cases is the place where she will be most 
likely to get well, and you are sent to take her there. Some 
patients will be glad to come; others will be too excited or 
stupid to appreciate your explanations ; still others will violently 
object. 

If you have any doubts about being able to handle the case 
alone, get some judicious person to accompany you a whole 
or a part of the way, as necessity demands. You will usually 
find, however, that the railroad officials will render you all the 
help necessary, and in many instances the patient's behavior 
is far better as soon as she gets away from the friends and finds 
herself with a kindly disposed stranger who lets her understand 
that she considers whatever is reprehensible in her behavior as 
due to illness, to a sick mind, and not to willfulness or depravity. 

On the journey attention should be paid to the patient's 
comfort; to the evacuation of bowels and bladder; to nourish- 
ment and rest if the journey is a long one; and to protection 
from cold if the weather is severe. See that drinking water is 
offered to excited and feverish patients; that tactful means are 
used to divert or entertain certain ones; and in every way strive 
to inculcate self-control and seemly conduct. Discourage the 
curiosity of fellow-travelers by quiet dignity. Sometimes you 
will meet with most impertinent prying into your own and the 
patient's affairs. Treat such persons with courteous but dignified 
rebuffs. Accept friendly offers for assistance if you need them; 



396 NURSING THE INSANE [Chap. XXIX 

and, if you do not, your thanks are always due the one making 
the offer. 

You will generally find that it is better to take the front seat 
in a car with an excited patient, for if she is inclined to be hilari- 
ous, and is sitting in the rear of the car, the ill-concealed curiosity 
and amusement of those sitting in front, as they turn to stare 
at her, only serve to make her actions still more extravagant. 
It is well to have with you an illustrated magazine, as the pictures 
will often serve to divert a patient inclined to be noisy. 

On no account are you to leave the patient alone an instant. 
Accompany her to the water-closet, exercise the greatest care 
in getting out of trains, boats, and carriages and, without letting 
your surveillance be apparent or annoying, see that it is constant. 
One case in mind made the excuse of going to the water-closet, 
and jumped from the car window while the train was in mo- 
tion, thus committing suicide, when probably escape only was 
intended. 

Patients should be searched carefully for drugs or concealed 
weapons before taking them from home. Be lenient with pa- 
tients about little belongings which they wish to bring — photo- 
graphs, a favorite book or two, etc. ; but as a rule you should 
not burden yourself with any luggage except a hand bag con- 
taining the things immediately needed, as you should be free 
to give your entire attention to the patient. If the checking 
or care of luggage is likely to be of much trouble to you, by 
reason of changes, and you have in charge an obstreperous or a 
suicidal case, it is better to have the luggage sent on by express 
than to undertake to look after it. 

Try to make the friends understand, more by what you are 
than what you say, that the patient is going among friendly dis- 
posed persons who will do all that they can to care for her and aid 
in the recovery. By your own kindly manner you can do much 
to lessen the grief of those who are obliged to consign their friends 
to the care of strangers and to the wards of a State hospital. 

Seek to allay the fears of patients who seem to dread the 
entrance to the hospital by kind and reassuring words on the 
journey and by practical efforts on their arrival, to the end that 
an event so trying shall be made as easy for them as possible. 



Chap. XXIX] MISCELLANY 397 

On your return to the hospital, turn in your report of expenses 
to the steward, and your report to the physician of the environ- 
ment of the patient, her behavior at home and on the journey, 
and any facts that you learned of herself or family that have any 
bearing on the case, together with the name and address of the 
correspondent for the patient. 

Care of the Dying and Dead. — It is the nurse's duty to see 
that a dying patient has an opportunity to receive the last 
sacraments, or at least to see a clergyman, if he so desires. In 
the case of Roman Catholics a priest should be sent for whether 
the patient is conscious and desires to see one, or refuses, or is 
even unconscious. 

In hospital practice there will be no difficulty in summoning 
a physician to the bedside of a dying patient whenever a change 
for the worse is observed, and this should always be done. In 
private practice the physician should be informed if death seems 
approaching, and if he does not arrive in time, he should be 
notified at once when death occurs. 

The nurse should give the patient a chance to see his friends 
if they can be summoned while he is still conscious. Everything 
should be done to make the last hours as comfortable as possible, 
and the nurse should stay with the patient to the end. 

The signs of approaching death are what is known as the 
Hippocratic face — sunken eyes, a sharp nose, collapsed temples, 
cold ears, with the lobes turned outward, the skin of the fore- 
head parched, the face livid, lead-colored, or brownish — cold 
extremities, clammy skin, and steadily failing heart's action, 
perhaps muscular twitchings and stupor, and the ominous 
" death rattle " in the throat. 

The dying patient should aways be removed from the ward 
if practicable; if not, he should be carefully screened, and the 
other patients spared as much as possible from seeing and know- 
ing about the event. 

The nurse should note and record the exact time of the death, 
and this, with the full name of the patient and the ward location, 
should be written on a paper and pinned to the nightgown on the 
patient, if the body is sent to an undertaker, and on the winding 
sheet, if the body is sent to the morgue. 



398 NURSING THE INSANE [Chap. XXIX 

When the end comes, straighten the limbs, close the eyes, put in 
artificial teeth, if such are worn, and then, if friends are there, 
leave them alone with their dead for a while. If the eyes do 
not remain closed, insert a wisp of cotton under each upper lid 
and pull the lid well down over it. After that, wash the body 
with soap and water and a 1 to 40 carbolic solution. Pack 
the nostrils, mouth, rectum, and vagina with cotton, and put on 
a diaper. In packing nostrils and mouth, be particular not to 
distort the features. Cover bruises and wounds with cotton and 
collodion. Tie the feet and knees together with a broad bandage, 
support the chin by a roller bandage placed under it, resting 
against the chest, but softened at the end with cotton, so the 
pressure will leave no mark on the chin, and fold the arms across 
the chest. Arrange the hair neatly in its accustomed way, 
pay particular attention to the finger and toe nails, and dress 
the body in nightgown and stockings. Cover the body with a 
clean sheet, put the room in order, and remove all signs of 
illness. 

The positive signs of death are very few. Absence of breathing 
is not a sure sign, for this takes place during fainting, or when 
a person is in a trance. Breathing may be so faint as only to 
be detected by the most delicate of tests. Hold a hand mirror 
in front of the mouth. If it becomes moist, respiration, though 
feeble, is still going on. The apparent cessation of the heart beat 
is not to be relied upon unless the physician, listening with a 
stethoscope, fails to hear it beat. It must be remembered, too, 
that coldness of the body and rigidity are observed in cataleptic 
states. It is especially important in cases of what appear to be 
sudden death to make sure that the person is really dead. The 
stethoscope test has already been mentioned. The circulation 
is tested by tying a string tightly around a finger; if the tip 
becomes blue, life is still there; but if there has been severe 
hemorrhage, it may not show blue, even if the person still lives. 

In a doubtful case, the physician sometimes gives a hypodermic 
injection of ammonia. If a red spot forms, it shows the person 
to be alive. Or if a needle be thrust in the flesh, and the part 
bleeds, you may know life is not extinct. Another test is to 
hold the hand in front of a bright light. If the normal pink 



Chap. XXIX] MISCELLANY 399 

line observed between the fingers with the hand so held is re- 
placed by a yellow line, it is said to be a sure sign of death. 

Rigor mortis is the rigidity of the muscles that comes on at 
variable periods after death. It shows itself in the jaw first 
and spreads downward. In some cases it comes on ten or fif- 
teen minutes after death, in others from twelve to twenty-four 
hours. It disappears in the same order, leaving the body limp 
and utterly relaxed. Another probable sign of death is the 
lividity seen in dependent parts due to congestion of the blood 
in the capillaries. 

In most cases after death the body gradually cools, being quite 
cold in from six to twelve hours, but in certain diseases the 
bodily temperature remains high, or continues to rise for some 
time after death, e.g. cholera, yellow fever, and general paresis. 

Putrefaction is the conclusive proof that death has taken place. 

If a person dies of some infectious disease, the body should be 
bathed in a strong disinfectant, and wrapped in a sheet wrung 
out of a 5% carbolic acid solution, and the sheet kept wet by 
sprinkling from time to time. The funeral should be private, 
and in private nursing the nurse usually stays with the family 
to superintend the fumigation of the room. 

Autopsies. — The trained nurse's attitude toward the question 
of autopsies should never be such as to dissuade the friends from 
consenting. Realizing as she must how every autopsy adds to 
the sum of medical knowledge, she should at least not discourage, 
if she cannot encourage, the friends to give their consent. The 
nurse should, of course, never discuss the findings of an autopsy, 
any more than she should the details or the treatment of a case. 
It is the province of the physician to enlighten the relatives as 
to the findings; others have no right to know the facts unless 
the friends choose to furnish them. 

Autopsies are best done soon after death, before putrefactive 
changes take place, and before the undertaker embalms the 
body. The body is prepared as previously described, except 
that no clothing is put on but the diaper, after which the body 
is wrapped in a sheet. 

The hair of women patients, if long, is to be parted over the top 
of the head in a straight line from ear to ear, and each portion 



400 NUESING THE INSANE [Chap. XXTK 

brought well away from the part and braided, one braid hanging 
forward and one backward, or, still better, one being coiled and 
pinned securely in front of the part, and the other similarly 
coiled on the other side of the part. By this arrangement the 
incision in the scalp is easily made and the hair is kept clean 
and out of the way. 

If the autopsy is to be performed in a private house, the carpet 
should be protected with oilcloths, rubber sheets, or old papers. 
There should be a stand for instruments, three wash bowls, 
two pails of water, hot and cold, old towels, and a large sponge 
or two. There should be oakum or cotton batting to pack the 
cavities, and some small, wide-mouthed bottles for specimens. 
The physician will usually bring these, as well as his instruments, 
needles, and suture material. 

The nurse should remove all blood stains from the body or 
elsewhere, should remove all signs of the autopsy, put the room 
in perfect order, ventilate it thoroughly, and if necessary, burn 
a little coffee on a shovel to dispel the odor. The patient's 
body should then be dressed in nightgown and stockings, and 
covered with a clean sheet, to be further attended to by the under- 
taker. 

Patients dying in State hospitals should be clothed with the 
best of their own clothing if it is good enough, or if not, with a 
burial outfit provided by the State. 

As soon as the patient's clothing has been returned from the 
laundry, it and all the rest of her clothing and belongings should 
be packed and listed and sent to the office for shipment to the 
friends. Jewelry, money, and other articles in the safe belong- 
ing to the patient should be sent at the same time. 

If the relatives visit the hospital afterward and ask for the 
nurse, the latter should take pains to recall as comforting things 
as she can to tell them about, but should omit distressing details. 
As to information concerning the medical aspect of the case, 
the nurse should refer the friends to the attending physician. 



INDEX 



Abdomen, preparation for examination, 
135; operations on, 189, 190, 192-193, 
194-195. 

Abdominal compresses, see Compresses. 

Ablution, 94-95. 

Abortion, threatened, 204, 205. 

Abstinence symptoms, 315-316, 359. 
See also Drug habitue^ 

Abusive patients, 265-266. 

Accidents, see Emergencies. 

Acid burns, 154; poisons, 163. 

Acts, impulsive, 302, 318, 340. See also 
Ideas, imperative. 

Acute mania, see Manic-depressive in- 
sanity. 

Addison's disease, 141. 

Administration of Medicines, see Medi- 
cines. 

Adornment of wards, see Wards. 

Affusion, 96, 171. 

Aged patients, see Senile insanity. 

Air, composition, 61; nature's means of 
purification, 62. See also Ventilation. 

Alcohol, use of , in employees, 19; ad- 
ministration to patients, 19, 27. 

Alcoholic delusional insanity, 312-314. 

Alcoholic habitue^ see Drug habitue^ 

Alcoholism, acute, 310-311; chronic, 
311. 

Alienation, 287. 

Alkali, burns, 154; poisoning, 163. 

Almshouse, patients conveyed from, 394. 

Altruist, 251, 274. 

'* Americanitis, " 344. 

Amnesia, 297. 

Amusement of patients, 22, 29, 33, 51, 
58-59, 210, 213-222, 354. See also 
Occupation of patients. 

Anemia, 97, 98, 108, 225, 307, 368. 

Anesthesia, 186-191, 206, 303, 304, 366. 

Anesthetics, 149, 186; local, 191. 

Angina pectoris, 103, 181. 

Anorexia, 136. 

Antidotes for poisons, 163. 

Antiseptics, 183-184. See also Disin- 
fectants. 

Antitoxin in diphtheria, 173-174. 

Aphasia, 303. 

Apomorphia, 162. See also Emetics. 

Apoplexy, 147. 

Appearance of patient, general, 131-132. 



Appendicitis, 178-179, 191. See also 

Abdomen. 

Application for State hospital service, 1, 
2. 

Artificial feeding, see Nasal feeding. 

Artificial respiration, 149, 189, 206. 

Asphyxia, 148-149. 

Association of ideas, 284, 286, 290, 335. 

Asthma, 179. 

Attendants, denned, 2 ; requirements for 
applicants, 2; wages of, 3-4; cloth- 
ing, 2; time off duty, 2, 3; vacation, 
3; resignation, 2; dismissal, 2, 4; 
transfers, 4; duties of, 5; new, see 
Probationers. See also Nurses. 

Attention, power of, 240, 241, 242, 245, 
270, 347, 348, 354-355. 

Aura, 337-338, 373. 

Automatic acts, 211, 236, 253-254, 302, 
305. 

Automatic intelligence, 237. 

Autopsies, foreign bodies found, 137; 
nurse's attitude toward, 399; prepa- 
ration for, 399-400; in private 
houses, 400. 

Auto-suggestions, 376-377. 

Bacilli, 176. See also Bacteria. 

Bacteria, 152, 174, 183-184. 

Bandaging, 185. 

Bathing of patients, 32, 40-41, 46, 47, 
89-92, 96. 

Baths, uses of, 89; tub, 91, 172; reme- 
dial, 92-105; medicated, 112. 

Beards of patients, 32, 82, 176. 

Bed, airing, 68, 81; care of, 70, 71, 80; 
cradles, 78-79, 170; changing cloth- 
ing of, 75-77, 83, 84-85; bedding, 71, 
74, 75, 76, 79; making, 74-75; pan, 
85, 171, 175. See also Vermin. 

Bed patients, care of, 4, 30, 32, 73, 75-81, 
85, 89-91; conveniences for, 78-79, 
83-84, 87; feeding of, 117-119. See 
also Toilet of patients ; Bed sores. 

Bed sores, 38, 85, 86-88, 105, 170, 360, 
387. 

Bee stings, 152. 

Belongings of patients, 12-13, 32, 42, 57, 
80, 394, 396, 400. See also Clothing of 
patients; Valuables. 

Besetting sins, 263, 291. 



2d 



401 



402 



INDEX 



Bible, quoted, 9, 377. 

Birds, books concerning, 218. 

Bites, from insane patients, 152; from 

insects, 152. 
Bladder, attention to, 43, 84 ; irrigation, 

111-112, 122, 359, 360. See also 

Cystitis. 
Blows on head, 148. See also Scalp 

wounds. 
Body and mind closely related, see 

Mental states and bodily reactions. 
Borderland cases, 388. 
Bowels, attention to, 43, 84, 136, 180, 

368. See also Feces ; Enemata. 
Brain, 237, 238, 245, 260, 274, 277, 282- 

283, 286, 347. 
Brand bath, 100, 101-102. 
Breasts, care of, 204, 207. 
Bright's disease, 141, 181. 
Bronchitis, 179. 
Bruises, 151. 
Bulimia, 136, 331. 
Burns, avoidance, 129, 142, 360; kinds 

and treatment, 152-154. 
Burroughs, John, essays, 218; alluded to, 

266. 

Call, Annie Payson, quoted, 264-265. 

Camisole, see also Mechanical restraint. 

Carbolic acid burns, 154. 

Care of new-born child, 206, 207-208, 
386. 

Care of pregnant woman, 204. 

Catheterization, 122. 

Catholics dying, 397. 

Cauterization in hemorrhage, 158, 159. 

Centipede, doubting, 377-378. 

Cerebro-spinal fluid, see Lumbar punc- 
ture. 

Cerebro-spinal meningitis, 172. 

Certificate of lunacy, 391. 

Cervix operations, after care, 204. 

Changing beds, see Beds. 

Charge attendants, wages of, 3. See also 
Charge nurse. 

Charge nurse, wages of, 3 (see also 
Charge attendants) ; duties, 5, 22, 23, 
26, 27, 28, 32, 39, 49-59, 66, 70; effi- 
ciency, 49; executiveness, 32, 49-50, 
68, 70; influence of, 50-51, 58; tact 
of, 50-52, 55, 56 ; hostess of ward, 51- 
52; instruction of subordinates, 52- 
53, 55-56, 82 ; patience with beginners ; 
52-53; qualifications, 54, 55, 59, 
active interest in welfare of patients, 
51, 58; report of conditions, 54, 55; 
keeping of memorandum, 54. 

Chest, preparation for examination, 
133-134; compress, 106-107. 

Chilblains, 156. 

Choking, treatment, 149-150. 

Chronic patients, care, 7, 8-11, 14, 353- 



357; stimulation, 9; improvement, 
9-10; humoring, 11-14; tact in 
management, 10-12 ; forbearance with, 
12-13. 

Chronic service, 8, 15. 

Chronicity, avoidance of, 7, 8, 11, 20, 21. 

Circular insanity, 328. See also Manic- 
depressive insanity. 

Civil Service examination for attendants, 
2. 

Classification of mental diseases, 308. 

Clothing, of patients, 32, 33, 38, 42, 57, 
200, 392-393, 400; changing, 75-78; 
removal of, 84-85, 154, 164-166; on 
fire, 154. 

Cocainism, 316-317, 359-360. See also 
Drug habitue. 

Cogitations, 247. 

Cognition, 247. 

Cold, see Exposure to cold. 

Cold bath, 92-93; cold full bath, see 
Brand bath. 

Cold pack, 98-100. 

Cold rub, 98. 

Collapse delirium, 309. 

Collecting propensity, 12, 13, 80. See 
also Ownership. 

Coma, 144-148, 156. See also Uncon- 



Commission in Lunacy, see State Com- 
mission in Lunacy. 
Compresses, 105-108; throat, 105-106, 

189; chest, 106, 107; abdomen, 107; 

hot fomentation, 107-108. 
Compulsive ideas, see Ideas. 
Compulsive insanity, 345-346. See also 

Impulsive insanity. 
Conceptions, 241. 
Concepts, 284, 285, 286, 296. See also 

Ideas. 
Condition of patient on admission, 36- 

38. 
Confinement cases, see Pregnancy. <See 

also Puerperal insanity. 
Conscience, 262. 
Consciousness, 241, 245, 247, 257, 259, 

299, 309, 326, 334, 343. 
Constipation, 136, 137, 164. See also 

Enemata. 
Constructive instinct, 271. 
Consumption, see Tuberculosis. See also 

Phthisis. 
Contagious diseases, 168-174, 394. See 

also Infectious diseases. 
Continuous bath, 104-105. 
Contusions, 151. 
Conveyance of patients to hospitals, 

393-397. 
Convolutions, 282-283. See also Brain. 
Convulsions, children, 102; epileptic, 

142, 145, 233, 337-338, 373; hysterical, 

146, 375; organic brain diseases, 304- 



INDEX 



403 



305; puerperal, 204, 206; uremic, 
102, 145-146, 181. 

Copper sulphate, 162. See also Poison- 
ing. 

Cord, tying, 205. See also Pregnancy. 

Correspondence, of patients, 44-46; 
about patients, 25, 394, 397. 

Corrosive poisons, 163. 

Cortex, see Brain. 

Cough, report of, 134. 

"Cranks," 335, 337. 

Crumbs, 80, 86, 87, 119, 371. 

Curiosity, instinct of, 269-270, 319, 352. 

Custodial care, 350. 

Cut throat, 159-160. 

Cystitis, 105, 109, 137. See also Bladder. 

Damocles, sword, 334. 

Danger signals of insanity, 293. 

Dead, care of, 398. 

Deaf-mutism, 303. 

Death, from contagion and infection, 
169, 399; signs of, 398-399. 

Deception of patients prohibited, 31, 34, 
395. 

Defective mental states, see Idiocy and 
Imbecility. 

Delirious mania, 329, 332. See also 
Delirious patients; Manic-depressive 
insanity. 

Delirious patients, 96, 98, 118, 127, 172, 
175, 357, 358, 359, 387. See also 
Exhaustion psychoses ; Delirium 
tremens. 

Delirium tremens, 233, 311-312, 359, 387. 

Delusions, 121, 123, 142, 284, 290, 291- 
292, 295, 298, 307, 312, 313, 317, 321, 
324, 335, 357, 368; nurse's attitude 
toward, 11-12, 31, 47-48, 221-222, 
335, 351, 367, 372. 

Demented patients, 67, 91, 118, 129, 149, 
155, 156, 209, 270, 271, 302, 303, 304, 
305, 306-307, 353, 354. 

Dementia paralytica, see General paresis. 

Dementia praecox, 133, 317-319, 354, 
360. See also Demented patients. 

Dementia, senile, 325-327 ; terminal, 300. 

Demulcents, 163. 

Depressed patients, 31, 91, 115, 118, 222, 
246, 249, 258, 260, 270, 276, 285, 288, 
300, 301, 302, 306-307, 308, 329, 362, 
363, 366, 367-368, 386 (see also 
Melancholia) ; manic-depressive in- 
sanity, 333-334. 

Destructive instinct, 271. 

Destructiveness, 20, 85, 271, 355. 

Deteriorated patients, see Demented 
patients. 

Diabetes, 98, 138, 181-182, 184. 

Diarrhea, 105, 109, 136-137. See also 
Dysentery; Bowels. 



Dining room attendant, wages of, 4; 

113-116. 
Dining rooms, 64, 113. 
Diphtheria, 105, 173-174. See also 

Antitoxin. 
Disinfectants, 127, 168, 183, 184. 
Disinfection, 168-169, 183, 184. 
Dislocations, report of, 38, 166. See also 

Fractures. 
Disorientation, 299. 
Distractibility, 330. 
Do instead of dream, 255, 278, 280-281, 

289, 360. 
Doubts, morbid, 377-378. 
Douche, 108; Scotch, 108; vaginal, 122, 

192, 199, 203, 205; nasal, 162. 
Dreams, 224, 233, 289-290; dreamy 

states, 299, 333, 339, 341, 343. See 

also Epilepsy; Hysteria. 
Dress of patient, observation of, 131. 
Dressing basket, 57-58. 
Drip sheet, 97-98. 
Dropsy, 180. See also Heart. 
Drug habitud, 191, 225, 290, 314, 359, 

360, 382. 
Dual personality, see Multiple personal- 
ity. 
Du Bois, Patterson, quoted, 352. 
Dust, 68, 69, 70, 194. 
Duties of nurses, 5. See also Rules for 

nurses. 
Dying, care of, 397. 
Dysentery, 120, 174-175. See also Ene- 

mata ; Bowels. 

Ecchymosis, 151. 

Economy of State property, 19, 54. 

Ego, 247-249, 286; alterations of, 131; 

complexity of, 248-251. 
Egoist, 251. 

Elated patients, see Excited patients. 
Eliot, George, quoted, 6, 291. 
Emergencies, 27, 28, 142-167, 186, 193, 

205; guarding against, 142-143; 

report of, 143. 
Emergency commitment, 392. 
Emetics, 162. 
Emotions, 132, 240, 274, 276-277, 278, 

282, 284-285, 287, 288, 300-301, 318, 

319, 322. 
Employment of patients, see Occupation 

of patients. 
Endocarditis, 180. 
Enemata, 120-121, 151, 170, 171, 179, 

186, 191, 199; nutrient, 121-122. 

See also Bowels. 
Enteritis, 178. See also Diarrhea. 
Enteroclysis, see Intestinal irrigation. 
Environment, influence of, 246, 260, 261, 

270, 275. 
Epilepsy, 91, 118, 142, 145, 146, 149, 



404 



INDEX 



233, 302, 337, 387. See also Convul- 
sions. 

Epileptic insanity, 337-341; treatment, 
372-373. See also Epilepsy. 

Epistaxis, 161-162. 

Erotic patients, 364-365. See also 
Masturbation . 

Eruptive fevers, 169. 

Erysipelas, 174. 

Examiners in lunacy, 390, 391. 

Excited cases, 120, 207, 219, 246, 260, 
270, 276, 285, 296-297, 307, 308, 
363-366, 370, 386, 396. See also 
Manic-depressive insanity. 

Excreta, disinfection, 168, 175, 178, 184. 

Exercise of patients, 22. See also 
Gymnastics. 

Exhaustion psychoses, 170, 309-310, 
357, 386. See also Toxic psychoses. 

Exposure to severe cold, 33, 156-157. 

Faculties of mind, 237-238, 240, 246. 
See also Mind. 

Fainting, 144, 157. 

"Falling sickness, " see Epilepsy. 

False beliefs, see Delusions. 

Fear, instinct of, 269; morbid, 37, 43, 
233, 323, 345-346, 377-378. 

Feces, 121, 137, 164, 168, 175, 178, 179, 
184, 365. See also Bowels. 

Feeble patients, 32, 36, 40, 75-77, 81, 83, 
90-91, 93, 95, 96, 98, 118, 142, 232, 
233, 368. 

Feeding, by persuasion, 123, 361; mix- 
tures, 125, 126; forced, see Nasal 
feeding. 

Fenelon, quoted, 257. 

Ferns, book concerning, 218. 

Fevers, treatment of, 170-172; rheu- 
matic, 175, 180. See also Cold pack. 

Fire, danger of, 69; clothing on fire, 154; 
in hospital, 154-155; drills, 155; pro- 
tection against, 234. 

First impressions, received by patients, 
34-35, 41. 

Fishhooks in flesh, 152. 

Flight of ideas, 286, 297. 

Floors, care of, 69. 

Flowers, books concerning, 218. 

Fomentations, 107-108. 

Food, serving of, 11, 12, 32, 113-119, 136. 

Foot bath, 112. 

Forced feeding, see Nasal feeding. 

Foreign bodies, esophagus, 137, 149-150; 
pharynx, 149; stomach, 137, 150; 
intestines, 137; vagina, 137, 150; 
urethra, 150; rectum, 137, 150. 

Foreign patients, 214. 

Fractures, 85; report of, 38; signs of, 
164; management, 164-165; in aged 
cases, 363. See also Dislocations. 

Friends of patients, 14, 24-25, 34, 117, 



361, 367, 380-383, 393, 394, 396, 397, 

400. 
Frost bites, 156. 
Fumigation, 66, 169. 

General anesthesia, see Anesthesia. 
General paralysis, see General paresis. 
General paresis, 86, 91, 118, 149, 297, 

320-323, 360, 386-387, 399. 
Generative organs, observation of, male, 

90, 140; female, 90, 140, 199. See 

also Masturbation. 
Genius, 289, 335. 

Germ theory, 183. See also Bacteria. 
Germicides, 184. See also Disinfectants. 
Germs, see Bacteria. 
Glass swallowed, 150. 
Globus hystericus, 306, 337, 342. 
Golden rule, 35, 369. 
Gossip, abstinence from, 5, 24, 25, 46, 56, 

57. 
Graduated baths, 101. 
Grand mal, 337-338. See also Epilepsy. 
Grandiose ideas, 298, 304, 321-322. 
Gymnastics, 22, 212, 218-219, 220. 
Gynecological examinations, preparation 

for, 198-201 ; assistance during and 

after, 200-203; positions, 201-202. 

Habits, breaking up, 9-11, 85; of nurses 
and attendants, 19; power of, 225, 
252-255, 280. 

Hair, care of, 9, 10, 32, 82, 91. See also 
Shampoo. 

Half bath, 95. 

Hallucinations, 233, 284, 287, 290, 292, 
294-295, 310, 312, 314, 316, 319, 326, 
336, 384 et al. See also Illusions. 

Hammock bath, 104-105. 

Handwriting, 320, 329, 334. 

Head, blows and falls, 148 ; wounds, 158. 

Heart, stimulants, 163; lesions, 96, 119, 
180; palpitation, 180-181; symp- 
toms, 134. 

Heat exhaustion, 148. See also Sun- 
stroke. 

Heat, sterilization by, 184. 

Hematemesis, see Hemorrhage (Stomach) . 

Hematoma, 152. 

Hemiplegia, 147. 

Hemoptysis, see Hemorrhage (Lungs). 

Hemorrhage, 157-162, 195; nose, 161- 
162; mouth, 161; stomach, 161; 
lungs, 161; rectum, 196, uterus, 196; 
abdomen, 196; vagina, 204—205. 

Hemorrhoids, 109, 161. 

Hernia, 164. 

Hiccough, 179. 

Hip bath, 109. 

Hippocratic face, 397. 

Home nursing of insane, 380-384. 

Honor, sense of, 23, 28, 45. 



INDEX 



405 



Hospital departments, 21, 29, 37, 43, 57, 
65, 68-69, 70, 81 ; serving food in, 113, 
116-117; ventilation, 62, 65-66, 74- 
75. 

Hot baths, 102-103. 

Hot fomentation compress, 107-108. 

Housekeeping, 19, 54, 68-75, 113-114. 

Hugo, Victor, Les Miserables, 239. 

Hydriatrics, see Baths. 

Hydrotherapy, see Baths. 

Hygiene, physical, 8-9, 259, 275, 353; 
mental, 259, 268, 273-281; of the 
ward, 19, 20-21, 54, 60-72. 

Hyperesthesia, 303, 304, 342, 365. See 
also Sensibility. 

Hypersensitiveness, 315, 374, 378. See 
also Hyperesthesia. 

Hypnotism, 224, 344, 352, 377. 

Hypodermic injections, 148, 185, 186. 

Hypomania, 329, 331. See also Manic- 
depressive insanity. 

Hysteria, 98, 133, 146, 297, 299, 302, 303, 

304, 307, 341-344, 374. See also 
Anesthesia. 

Hysterical insanity, see Hysteria. 

Ice coils, 171. 

Ideas, 274, 283, 284, 285, 286, 289, 293 ; 
flight of, 297; imperative, 286, 297, 

305, 306; compulsive, 378; grandiose, 
298, 304, 321-322. 

Idiocy, 283, 302, 347, 348, 379. See 

also Imbecility. 
Illusions, 233, 284, 292, 294-295, 312, 

313, 314, 326 et al. See also Sense 

deceptions. 
Imagination, 241. 
Imbecility, 302, 347-348, 379. See also 

Idiocy. 
Imitation, instinct of, 270. 
Imperative ideas, see Ideas. 
Improvised splints, see Splints. 
Improvised stretcher, see Stretcher. 
Impulses, native, see Instincts; morbid, 

347. 
Impulsive acts, 143, 302, 306, 318, 340, 

347, 355. 
Impulsive ideas, see Ideas. 
Impulsive insanity, 346-347. See also 

Compulsive insanity. 
Inattentive patients, teaching of, 354. 
Incoherence, 297. 
Incontinence of urine, 138. See also 

Urine. 
Incorrigible patients, 352. 
Individualizing patients, 8, 11, 12, 14, 

22, 31, 47, 48, 80, 85, 117, 212, 

226. 
Infection psychoses, see Toxic psychoses. 
Infectious diseases, 100, 168-178, 184, 

399. See also Contagious diseases. 
Infirmaries, see Hospital departments. 



Inflammatory rheumatism, see Rheu- 
matic fever. 

Influenza, 102. 

Insane, number in New York State 
institutions, 1. 

Insanity, 46, 286, 288, 289-291, 293 et al. 

Insanity law, 390-392. 

Insight, 34, 287, 290. 

Insomnia, 98, 102, 180, 224-226, 231- 
232, 277, 285, 308, 312, 315, 331, 359, 
366, 368. See also Sleeplessness. 

Instincts, native, 268-271, 273, 279, 353. 

Intellectual field, observations of, 132. 

Intelligence, 246, 283. See also Knowl- 
edge. 

Intelligent acts, 237. 

Intestinal irrigation, 111. 

Intestinal obstruction, 179. 

Intoxication psychoses, see Toxic psy- 
choses. 

Introspection, 237, 246, 270, 280, 288. 

Intubation, 160, 174. 

Inventory of ward furnishings, 54. 

Involution psychoses, see Melancholia; 
Senile insanity. 

Ipecac, 162. See also Poisoning. 

Irrigation, 109-112. 

Irritant poisons, 163. 

Isolation, 168, 172, 173, 356, 363, 366, 
375, 380. See also Seclusion. 

Ivy poisoning, 152. 

Jacksonian epilepsy, 337, 338. 

James, William, quoted, 236, 253, 255, 

276. 
Jealousy, insane, 313-314, 317. 
Jean Valjean, 239. 
" Jekyll, Dr., "referred to, 299. 
Judgment, 224, 241, 246, 266, 269, 283, 

284, 286, 289, 292, 293, 298, 301, 337. 

Keys, care of, 27, 33. 

Kidneys, baths to stimulate, see Uremia. 

See also Intestinal irrigation. 
King, Professor, quoted, 280. 
Knowledge, 241, 246; objective, 237; 

subjective, 237. 
Krafft-Ebing, referred to, 222. 

Labor, see Pregnancy. 

Laboratory, specimens sent to, 43, 123, 
138-140. 

Lactational insanity, see Puerperal in- 
sanity. 

La Grippe, 172. 

Laparotomy cases, 195. See also Abdo- 
men. 

Lavage, 109-110, 179, 186. See also 
Stomach tube. 

Les Miserables, 239. 

Letters, about patients, 25 ; of patients, 
44-46, 57. 



406 



INDEX 



Liberty, deprivation of, 7, 13, 31, 350, 
381. 

Licensed sanitaria, number, 1. 

Lifting patients, 76-77. 

Ligation of arteries, 158, 159. 

Local anesthetics, 191. See also Anes- 
thetics. 

Local applications, 127, 129. 

Local treatment, 198. 

Lotions, 127. 

Love, instinct of, 269. 

Lumbar puncture, 196-197. 

Lunacy Commission, see State Commis- 
sion in Lunacy. 

Lunacy examiners, 390, 391. 

Lung gymnastics, 218-219. 

Male employees, on women's wards, 26. 

Malicious patients, 267, 351. 

Malingerer, 130. 

Management of pregnancy, 205-206. 

Management of ward, 23, 29, 49-59; 
system in work, 49, 55 ; assignment of 
duties, 49, 68; discipline, 50, 55-56; 
carrying out orders, 54; attention to 
details, 54-55; inventory, 54; sur- 
veillance, 55 ; transfer of patients, 56 ; 
parole patients, 57; supplies, 57. See 
also Housekeeping. 

Mania, acute, 328. See also Manic- 
depressive insanity. 

Maniacal conditions, 285, 297, 302, 306, 
328-331. 

Manic-depressive insanity, 324, 328-335, 
363-369. See also Depressed patients ; 
Excited patients. 

Mannerisms, 305, 319. 

Massage, 129, 167, 191, 225, 368. 

Masturbation, 85, 90, 140, 210, 302, 317, 
365, 378. 

Maudsley, referred to, 352. 

Measles, 173. 

Mechanical feeding, see Nasal feed- 
ing. 

Mechanical restraint, application of, 28, 
46, 47, 191, 358, 369-371; permis- 
sion for, 28. 

Medicated baths, see Baths. 

Medicines, care and administration, 26- 
27, 127-129, 232, 321, 362. 

Melancholia, 96, 323-325, 360-362. See 
also Depressed patients. 

Memory, 239, 282, 292, 293, 294, 296, 
297, 315, 318, 321, 325. 

Meningitis, cerebro-spinal, 172. 

Menstrual disorders, 103, 109, 112, 140, 
307. 

Mental states and bodily reactions, 236, 
238, 245-246, 249, 260, 262, 273-274, 
276, 292, 304, 306. 

Meyer, Dr. Adolf, quoted, 273. 

Mind, 236, 237, 238, 240, 246, 292. 



Minor operations, 193, 196. See also 

Surgical technique. 
Miscarriage, threatened, 204-205. 
Moods, 264, 284. 
Moral needs of patients, 7, 11, 14, 31, 35, 

48. 
Morphinism, 225, 314-316, 359, 360. 

See also Drug habitue\ 
Motor expressions of insanity, 304. 
Moving injured person, 165, 166. 
Multiple personality, 229, 343. See also 

Hysteria. 
Mumps, 172. 

Munchausen, referred to, 321. 
Muscular incoordination, 305. 
Mushroom book, 218. 
Music on wards, 51, 52, 216, 220. 
Mutism, 303. 
Mysophobia, 346. 

Nails, care of, 30, 90. 

Narcotic poisons, 163. 

Nares, plugging, 162. 

Nasal douche, 162. 

Nasal feeding, 123-126, 149. 

Native instincts, see Instincts. 

Native reactions, 269-271. 

Nature study, 216-218. 

Needles in body, 152. 

Negativism, 305. See also Will. 

Neptune girdle, 107. 

Nerves, motor, 240; sensory, 240, 242, 
253. 

Nervous prostration, see Neurasthenia. 

Nervous system, 238-239, 240-241, 242- 
243, 246, 253, 259, 266, 283. 

Neurasthenia, 97, 98, 108, 129, 225, 277; 
acquired, 344, 374; congenital, 345. 

Neurotic children, training, 277. 

New York State Hospitals, 1-2. 

Night nurses, 3, 30, 57, 71, 86, 139, 228- 
235. 

Night reports, 230. 

Night sweats, 94, 177, 178. See also 
Tuberculosis. 

Nightingale, Florence, quoted, 49. 

Nightmare, 224. 

Nipples, 204, 207. 

Noise, avoidance of, 21-22, 208, 230- 
231, 232, 246, 356. 

Normal salt solution, 148, 171, 184-185, 
190, 196. 

Nosebleed, 161-162. 

Nurses, duties, 5, 24; arduousness of 
work, 6, 15-16; wages, 2, 3, 4; quali- 
fications, 6, 7, 23, 24; necessity for 
growth, 7, 14, 15; influence of, 14; 
rules for, 17-33; appearance and 
dress, 18-21; unbecoming habits, 19; 
behavior, 19, 23, 25, 26, 33, 52, 56; 
duties to one another, 24; to officers, 
24; to friends of patients, 24, 25; 



INDEX 



407 



sense of honor, 28, 228, 234; self- 
control, 46, 47, 275; discretion, 195, 
203, 399, 400. See also Attendants; 
Uniforms; Night nurses; Training 
school. 
Nutrient enemata, 121-122. 

Objective symptoms, 131-132. See also 
Symptoms. 

Observation of symptoms and condi- 
tions, see Symptoms. 

Obsessions, 306, 346. See also Ideas. 

Obstetrical nursing, 174. See also Preg- 
nancy. 

Obstruction, intestinal, 179. 

Occupation of patients, 19-20, 29-30, 33, 
44, 58, 70, 75, 81, 209-213, 354, 357. 

Open-door system, 350. 

Operations, minor, 193, 196. See also 
Surgical technique. 

Optimism, 8, 258, 273-274, 322. 

Outdoor amusements and interests, 20, 
58, 216-218, 334. 

Overwork, 375-376. 

Ownership, instinct of, 271. See also 
Collecting propensity. 

Pack, cold, 98-100. 

Pain habit, 253. 

Pallor, significance, 140. 

Palpitation of heart, 180-181. See also 
Heart. 

Paranoia, 289, 335-337, 371-372. 

Paroles, 56-57. 

Patients, number in New York State 
Hospitals, 1 ; consideration for, 11-14, 
29, 31, 38, 39-43, 47, 48, 69, 70, 115, 
187, 201, 395; fastidious care of, 8, 30, 
90; reception of, 31, 34-44; general 
care of, 10, 32 ; general appearance, 
131; behavior, 132; general training 
of, 212. See also Occupation of 
patients. 

Perception, 241, 243-244, 282, 294. 

Perineal operations, after care, 204. 

Personality, dual, 299; multiple, 299. 

Persuasion, 36, 128, 257, 260, 352, 379, 
395. 

Perversions, 300, 302. 

Pessimism, 259, 273-274, 277. 

Peterson, Dr. Frederick, referred to, 371. 

Petit mal, 337, 338. See also Epilepsy. 

Phobias, 345-346, 378. See also Fear. 

Phthisis, 94, 98, 133, 140, 176, 307. See 
also Tuberculosis. 

Pillows, arrangement, 77, 78. 

Placenta, 184, 206. 

Plasticity, 252-253. 

Pleurisy, 179. 

Pneumonia, 140, 175-176, 180, 183, 184. 

Poison ivy, 152. 

Poisoning, 162-163. 



Poisonous gases, 148-149. 

Poisons, care of, 127. 

Powder burns, 154. 

Precocious children, 277. 

Precocious dementia, see Dementia prae- 

cox. 
Pregnancy, 184, 204, 205-206. 
Preparation for operations, see Surgical 

technique. 
Pride, instinct of, 271. 
Private households, insane in, 380-388. 
Probationers, 2, 24, 27, 52-53, 57, 349. 
Protection sheet, see Mechanical re- 
straint. 
Psychasthenia, 97, 346, 375-376, 378- 

379. 
Psychiatry, 282, 308 et al. 
Psychic epilepsy, 339. 
Psychic treatment, see Psychotherapy. 
Psychology, 236-251, 254, 263-272, 282- 

284, 368, 369 et al. 
Psychopathic states, 344-347. See also 

Psychasthenia. 
Psychotherapy, 256-262, 264 et al. 
Puerperal insanity, 207-208, 386. 
Pugnacity, instinct of, 270. 
Pulse, observations, 37, 38, 134-135, 206, 

245, 307 et al. 
Punctured wounds, see Wounds. 

Quarantine, 173, 174. 

Reaction time, 243. 
Reading, value of, 210, 215-216. 
Reasoning, 241, 246, 269, 292, 336 et al. 
Reception of patients, 31, 34-43. 
Rectal feeding, 121-122, 160. See also 

Enemata. 
Reduction, mental, 299, 303. See also 

Dementia. 
Reflex acts, 238. 

Reflexes, disturbances in, 304, 310. 
Relaxation, 228, 281. 
Report of symptoms and conditions, see 

Symptoms. 
Resistive patients, 36, 46, 47, 91, 120, 

121, 122, 124, 126, 127, 150, 201, 394, 

395, 360. 
Respiration, artificial, 148, 149, 206; 

observations, 37, 38, 133, 307. 
Responsibility, 261. 
"Rest cure," 374-375. 
Restlessness, 22, 191, 225, 308, 325-327, 

355, 387, 388. See also Senile insanity. 
Restraint, see Mechanical restraint. 
Resuscitation, from anesthesia, 188; 

of new born, 205-206. 
Retardation, 243, 285, 297, 333, 368. 

See also Reaction time. 
Retention of urine, 122, 138. See also 

Urine. 
Rheumatic fever, 103, 175, 180. 



408 



INDEX 



Rigor mortis, 399. 

Roman Catholics, 397. 

Rules for nurses and attendants, 17-33. 

Rumination, mental, 346. 

Safety sheet, see Mechanical restraint. 

Salem witchcraft, 291. 

Saline enemata, see Normal salt solution. 

See also Enemata. 
Sane delusions, 291. 
Sane hallucinations, 295. 
Sanitaria, licensed, unlicensed, 1; nurs- 
ing in, 388-389. 
Scalds, 152-154. 
Scalp wounds, 151-152. See also 

Wounds; Hemorrhage. 
Scarlet fever, 169, 180, 184. 
Scotch douche, 108. 
Scybala, 137. See also Feces. 
Seat of intelligence, 283. See also Brain. 
Seclusion, 28, 31, 46, 47, 356, 369. See 

also Isolation. 
Secretions, altered, 306-307, 331. 
Self, 248-251, 258, 342. See also Ego. 
Self-abuse, see Masturbation. 
Self-mutilation, 303, 353, 386. 
Senile insanity, 91, 98, 142, 225, 232, 270, 

304, 308, 325-327, 362-363, 387-388. 
Senility, physiological, 325. 
Sensation, 239, 241, 242, 243-244, 246, 

247, 282, 283, 286. 
Sense deceptions, see Hallucinations; 

Illusions. 
Sensibility, 243, 246, 275, 300, 344, 358, 

366. See also Anesthesia; Hyper es- 



Sensorium, 224. 

Sensuality, 210. See also Masturbation. 

Serving of food, 11, 21, 32, 113-119. 

Sexual equivalents, 302. 

Shampoo, 40-41, 177. See also Hair; 

Beards of patients. 
Shaving for operations, 192. See also 

Surgical technique. 
Sheet bath, 96-97. 
Shock, 148, 153, 157, 184, 192, 195. 
Shortcomings, attitude toward, 263-266, 

280-281. 
Signs, of approaching death, 397; of 

death, 398-399. 
Silent symptoms, 131. 
Sitz bath, 109. 

Skin, grafting, 196 ; observations of, 140. 
Skull fractured, see Fractures. 
Sleep, importance of, 30, 223, 235, 334; 

disorders, 308; conditions favoring, 

226-227, 231, 232. 
Sleeplessness, see Insomnia. 
Smallpox, 184. See also Vaccination. 
Somatic sense deceptions, 296, 298. See 

also Sense deceptions. 
Somnambulism, 224. 



Sordes, 358. 

Special attendant, wages, 4. 

Speech disorders, 303, 305, 311, 320, 339. 

Sphygmograph, 245. 

Splints, 165. 

Sponging, 93, 94. 

Sprains, 38, 112, 166-167. 

Sputum, care of, 66, 85, 168, 175, 176- 
177, 184; observation of, 134; speci- 
mens, 138-139. See also Tuberculosis. 

Stains, removal, 74, 75. 

State Commission in Lunacy, 1, 4, 18, 
390. 

State Hospitals, number in New York, 
1; addresses, 1-2; management, 1; 
general plan, 4; service in, 2-5. See 
also Attendants; Nurses; Training 
schools. 

Status epilepticus, 339, 374. 

Steam, bath, 104; sterilization by, 184. 

Stereotyped movements and attitudes, 
305, 319. 

Sterilization, 184. 

Stigmata, physical, 317, 339, 347. 

Stings, 152. 

Stomach, contents, 122-123. See also 
Test breakfast; Lavage. 

Stomach tube, 122-123, 162. 

Stools, see Feces; Bowels. 

Strangulated hernia, 164. 

Strangulation, 149. 

Stretcher, 165. 

Stuporous cases, 43, 129, 170, 357-358. 
See also Delirious patients. 

Styptics, 159. 

Subconscious life, 242, 343-344. 

Subjective symptoms, 130-131, 132. 

Suggestion, 352, 376-377. See also 
Hypnotism; Persuasion. 

Suicidal patients, 27, 31-32,91, 114, 115, 
135, 143, 160, 176-177, 196, 200, 208, 
234, 306, 324, 342, 361-362, 368-369, 
375, 382, 383, 386, 396. 

Sulphate, of zinc, 162 ; of copper, 162. 

Sunstroke, 147. 

Supervisors, 23, 27, 42, 45, 49, 71 et al. 

Surgical technique, 184, 185-186, 191- 
194, 202-203. 

Suspicions, insane, 128, 207, 313-314, 
316, 336, 337, 372. See also Delusions. 

Sympathy, 6, 12, 14, 24, 35-36, 47, 48, 
234, 257, 260-261, 266, 269, 271-272, 
277, 352. 

Svmptoms, observation and report of, 8, 

"27, 32, 33, 36-39, 43, 53-55, 87, 128, 

134, 143, 177, 199, 206-207, 229-230, 

231, 233, 234, 307, 397; subjective, 

130-131, 132; objective, 131-132. 

Syncope, 144, 157. 

Table manners, of patients, 11. 
Tapping chest, see Heart. 



INDEX 



409 



Tartar emetic, 162. 

Taxis, 164. 

Teeth, care, 10, 30, 83, 115; removal 
before anesthesia, 187. 

Telephone, 57. 

Temperature, baths, 92; patients, 37, 
135, 147, 177, 307, 357; wards, 66-67. 

Test breakfast, 122-123. 

Test phrases, 303, 320. 

Therapeutics, 256. See also Psycho- 
therapy. 

Thermometer, bath, 92; use of, 135, 150; 
ward, 66. 

Thirst after operations, 190, 194. 

Thorndike, Edward L., quoted, 279. 

Throat, specimens from, 140 ; compress, 
105-106, 189. See also Diphtheria. 

Toilet of patients, 30, 81-83, 90. 

Tonsilitis, 105, 178, 180. 

Tourniquet, 158, 195. 

Toxic psychoses, 191, 207, 225, 233, 296, 
302, 310-317, 358-359. See also 
Exhaustion psychoses. 

Toxins, 184. 

Tracheotomy, 160, 174. 

Training School for Nurses, 1, 2-3, 57, 
202; examinations, 3; length of 
course, 3 ; nature of course, 3 ; gradua- 
tion, 3; lectures, 120; discipline, 382. 

Transfers, patients, 56; nurses and 
attendants, 4. 

Transfusion, 171. 

Transportation of patient, see Convey- 
ance of patients. 

Trees, books concerning, 218. 

Tremors, 304, 311, 320. 

Trephining, 165-166. 

Trophic disorders, 86, 306, 320. See also 
Bed sores. 

Tubercular wards, 113. 

Tuberculosis, 66, 139, 176-178, 218-219. 

Turpentine stupes, 171, 179, 190. 

Twenty-four hours ' specimen, 139. See 
also Urine. 

Typhoid fever, 100, 170, 171, 184. 

Ulysses and the sirens, 260, 280. 

Unclean patients, 21, 70, 79, 80, 81, 84, 
85, 87, 121, 177, 228-229, 234, 353, 
355, 356, 370. 

Unconsciousness, 96, 118, 129, 144-148, 
149, 189, 247. See also Coma; Sleep. 

Uniforms, 2, 17, 18, 56. 

Unreality, sense of, 300, 324. 

Untidy patients, see Unclean patients. 

Uremia, 102, 138, 181, 184, 225 ; con- 
vulsions in, 145-146; treatment, 146. 



Urine, specimen after admission, 43, 139; 

observation of, 137-138, 186, 204; 

suppression, 138. See also Bladder. 
Uterine disorders, 109 ; hemorrhage, 109 ; 

prolapsus, 109; leucorrhea, 140. See 

also Menstrual disorders. 

Vacation, 3. 

Vaccination, 172-173; virus, 173. 

Vaginal douches, 112, 122, 199. 

Vaginal irrigation, see Vaginal douches. 

Vaginal operations, 192. 

Valjean, Jean, 239. 

Valuables of patients, 394, 400. See also 
Belongings. 

Valvular heart lesions, 180. 

Vapor baths, 103-104. 

Varicose veins, 159. 

Vaso-motor manifestations, 306. 

Vegetative functions, 238, 307. 

Ventilation, 21, 54, 60-67, 113, 231, 232- 
233. 

Verbigeration, 303. 

Vermin, 38, 41, 70, 73. 

Violent patients, 22-23, 27, 33, 41, 46, 
121, 125, 164, 200, 201, 355-356 et al. 

Virus, 173. 

Visitors on wards, 24-25, 26, 32, 52, 57, 
70. 

Vital functions, changes in, 307. 

"Voices, " 287, 319. See also Hallucina- 
tions. 

Volition, see Will. 

Voluntary acts, 238. 

Vomitus, 136, 149, 162, 189. 

Wages, 2, 3-4. 

Ward, adornment, 19-20, 113, 212, 213; 
hygiene of, 19, 21, 60-72. See also 
Management of ward; Noise, avoid- 
ance. 

Warm full bath, 102. 

Washing stomach, 109-110. 

Weight, observations, 36-37, 55, 115- 
116, 117, 308, 324, 363. 

Wet pack, 98-100. 

Will, 259-260, 286, 292, 293, 301, 302- 
303, 305, 378. 

Winternitz Combination Compress, 
107. 

Witchcraft, 291. 

Worry, 274, 334 et al. 

Wounds, 151-152, 159, 160. 

Zinc sulphate, 162. See also Emetics. 



Primary 

Nursing Technique 



By ISABEL McISAAC 

Formerly Superintendent of the 
Illinois Training School for Nurses 

Cloth, i2tno, IQ7 pages, $1.25 net 

" Throughout the book the teaching is addressed to the making of efficient 
nurses, and not the production of half-educated physicians in the guise of 
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useful, and one which should be in the hands of all beginning their career as 
nurses." — Medical Record. 

"This useful manual by Isabel Mclsaac is admirably fitted for the use of 
probationers during their first year, and will save much bewilderment to the 
pupils who never clearly understand until they have seen directions in print. 
The practical chapters on giving baths, on bed-making, on symptoms, and on 
the administration of medicine are excellent. . . . The merit of the book 
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" It is impossible to study it with anything but the greatest interest. From 
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and teaching every subject strictly in its ' direct relation to nursing, not to 
medical practice.' Because this has not been done sufficiently in the past, or, 
being attempted, has not been thoroughly carried out, is one of the greatest 
causes of failure in the usual hospital curriculum of training. In their attend- 
ance at physicians' and surgeons' lectures, nurses learn much that is purely 
theoretical, so that while they can discourse glibly on the composition of air, 
the circulation of the blood, and the names of the bones of the skeleton in 
detail, they yet fail often to apply their knowledge to such simple matters as 
the proper ventilation of the ward or sick room, the application of warmth to 
a chilly patient, or to the prevention of bed sores over those same bony 
prominences whose names they know by heart. 

" To all matrons who take an active, personal share in the teaching and 
training of their nurses — and there ought to be none who do not — this book 
will prove a great help." — The Nursing Times. 



THE MACMILLAN COMPANY 

PUBLISHERS, 64-66 FIFTH AVENUE, NEW YOEK 



TEXT-BOOK OF 

Anatomy and Physiology 
for Nurses 

Compiled by DIANA CLIFFORD KIMBER 

Graduate of Bellevue Training School, formerly Assistant Superintendent 
New York City Training School, Blackwell's Island, New York, and 
Assistant Superintendent Illinois Training School, Chicago, 111. 

Second Edition, revised. Cloth, $2.50 net 



The book is the accepted standard in American Training 
Schools for Nurses. The extent to which it is in use is some- 
what indicated by the fact that since its first issue it has been 
necessary to reprint the book no less than twenty-one times. 

Its aim is to supply all that is essential for the training-school. 
It may well be used by any general reader who desires some 
reliable yet simple discussion of the subject. It is very fully 
illustrated. 

"From her long experience in teaching classes the author 
knows exactly what nurses need and how much can be reason- 
ably given them in the short space of two years' time, and for 
the assistance of the inexperienced teacher her book is arranged 
in lessons covering the first or junior year. The subjects are 
presented with sincerity and distinction, and illustrated by cuts 
and plates of unusual merit." — The Trained Nurse. 



THE MACMILLAN COMPANY 

PUBLISHERS, 64-66 FIFTH AVENUE, NEW YOBK 



APR 20 1908 




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